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Art3_Chino_FY13_Transit_Central_ClaimClaimant: City of Chino Date: Please see below instructions and checkmark the items included in your submittal. 1. Claim Form (one-time submission) – required prior to, or along with, your first reimbursement request. 2. Authorizing Resolution (one-time submission) – required within SIX months of the project award by SBCTA Board or prior to requesting reimbursement of funds, whichever comes first. Resolution should authorize the filing of the claim form, authorize the submission of reimbursement requests and designate the individuals authorized to certify project completion (Authorized Agent). Sample language is available upon request. 3. Reimbursement Request Form (as needed) – this form is required every time a reimbursement is requested. Please note, progressive payments are only eligible on awards over $200,000 and local match share percentage must be met regardless of reimbursement amount requested. 4. Backup Documentation (required with Reimbursement Request Form) – invoices, paychecks, purchase orders, etc. to support both the reimbursement and match amounts noted on the Reimbursement Request Form. Please note, staff administration and/or contract project management expenses are NOT eligible match expenses. However, staff expenses may qualify for local match under select circumstances. Please identify whether supporting documentation includes staff expenses under one of the following allowable conditions: Award is for an ATP Safe Routes to School (SRTS) program project, not a SRTS infrastructure project. Necessary staff time directly related to in-house completion of design, right-of-way acquisition, or construction including inspection and/or construction management. Note: No travel costs or per diems allowed for staff time 5. Certification of Completion (completed projects only) – prior to filing the final request for reimbursement, written verification of project completion by the agency’s Authorized Agent is required (see Authorizing resolution above). Sample language is available upon request. 6. Photos of Completed Project (completed projects only) – required when project is complete and should be attached to final reimbursement request. 7. Other (optional) – Claimants may attach additional information not included in this list to support the claim or reimbursement request. SBCTA may request additional information as necessary. Project Name: Central Avenue Sidewalk/Access Ramps Improvement Grant Allocation No: S-1407-03 Claimant: City of Chino Address: Attention: Phone No: E-mail Address: Award Amount 127648 Purpose: Please check one purpose. Article 3 Bicycle/Pedestrian Facilities, Public Utilities Code (PUC) 99233.3 Transit Stop Access Improvements, PUC 99233.3 Authorizing Signature: (Authorized Agent specified in Authorizing Resolution) Date: Signature Type Name & Title Condition of Approval: Approval of this claim and payment by the County Auditor to this claimant are subject to monies being available and to the provision that such monies will be used only in accordance with the approved allocation instruction. Claimant: City of Chino Allocation #: S-1407-03 Grant Information (completed by SBCTA) Project Name Total Project Cost Article 3 Award Amount Percent Article 3* Local Match ATP Funds Central Avenue Sidewalk/Access Ramps Improvement 156280 127648 0.81679037624776 28632 *Note: Actual share is forumal based. Instructions: Please complete 1 through 5 below. Amount 1) Article 3 Cost (amount being requested for reimbursement) 2) Local Match/ATP Funds Cost Field will change to red if local share is not met (not allowed). Field will change to green if local share exceed requirement (allowed). Total 0 Project Costs to Date (include amount requested above) 3) Article 3 Article 3 Balance Remaining 127648 4) Local Match Local Match 28632 5) ATP (if applicable) ATP Funds (if applicable) 0 Total 0 Total Amount Remaining 156280 I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge. (Authorized Agent specified in Authorizing Resolution) Signed: Date: