R 5344 TABLE 1
CITY PROJECTS
for
Agreement No. AG-FAST-02
SLOCOG# Project Name RSHA USHA Balance
Urban Area
SMAPAGO1U Apportionment FY $ - $ 413,400 $ 413,400
21/22-26/27; Local
Choice Funds
Halcyon Road Safe
SMAPAGO4R Routes to School $ 749,000 $ - $ 749,000
Improvements
SLOCOG RSTP Exchange/STBG General Cooperative Agreement page 5
EXHIBIT A
San Luis Obispo Council of Governments
Regional Surface Transportation Program Exchange (RSTP Exchange)
REIMBURSEMENT REQUEST FORM
Agency Name: Date:
Contact Person:
Project Number(s): Regional: Urban: •
Project Title:
This Invoice Covers Work Completed from: i i to:
Project Budget Information: (complete box below- refer to cooperative agreement
"Table 1"for budget information)
Total SPENT This invoice $ - When using electronic format:fill in unshaded areas only
Other Sources TOTAL
Regional Urban Non Regional (must equal 100%)
Reimbursement Rate by Fund
Source(must be consistent with Exhibit 0%
A Project Sheet)
Pro-rata Reimbursement by
Funding Source $ - $ - $ - $
(Regional/Urban)
Please send a check for$
Total RSTP Exchange share due this invoice (total of heavier shaded
boxes above)
Attachments: 1) A brief description of work completed; and
2) Consultant invoices
3) Proof of payment (e.g. copy of CITY check to consultant).
Signed:
(Agency Rep.)
Shaded boxes below for SLOCOG Use
Regional Planner Approval Accounting Initials
SLOCOG RSTP Exchange/STBG General Cooperative Agreement page 6