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Agency Name:

Office Authorized to Receive Payments:

Agency Name: Office Authorized to Receive Payments: Address 1: Address 2: Address 3: Grant Number: This

Address 1:

Address 2:

Address 3:

Grant Number:

This is the office or department that reimbursement checks should be made payable to and should match the Grant Agreement, Page 1 Section D. (OTS-38) (Cannot be an individual's name)

Grant Start Date:

Personnel Indirect Rate:

Contractual Services Indirect Rate:

Agency Information

EXHIBIT 5-A

City of Anytown

City of Anytown City Treasurer 2700 Main Street Anytown, CA 90001

City Treasurer

2700 Main Street

Anytown, CA 90001

City of Anytown City Treasurer 2700 Main Street Anytown, CA 90001
City Treasurer 2700 Main Street Anytown, CA 90001 Agency Name: Must match the Grant Agreement, Page

Agency Name: Must match the Grant Agreement, Page 1, Box 2

(OTS-38)

Address: Must match the Grant Agreement, Page 1, Section D.

PT1099

10/1/2009

0.00%

OR

(Indirect costs are allowed for only one of these)

0.00%

(Indirect costs are allowed for only one of these) 0.00% Must match the Grant Agreement Budget
Must match the Grant Agreement Budget Estimate, (OTS-38e)

Must match the Grant Agreement Budget Estimate, (OTS-38e)

STATE OF CALIFORNIA OFFICE OF TRAFFIC SAFETY

GRANT CLAIM INVOICE

EXHIBIT 5-A

For work performed under provisions of the California Vehicle Code, Chapter 1492 and the Public Law 8-564, Highway Safety Act of 1966 as amended

TO:

Office of Traffic Safety

Progress:

X
X

2208

Kausen Drive, Ste 300

 

Elk Grove, CA 95758

Final:

Elk Grove, CA 95758 Final:

FROM:

(Please remit

City Treasurer

 

payment to:)

2700

Main Street

 

Anytown, CA 90001

 

Grant No:

PT1099

Agency Name:

City of Anytown

Claim No:

2

Detail of Costs Reported From (Grant Start Date):

October 1, 2009

thru

March 31, 2010

TOTAL COST

TO DATE

LESS PRIOR

CLAIMS

NET AMOUNT

THIS CLAIM

PERSONNEL COSTS

49,250.57

0.00

49,250.57

TRAVEL EXPENSE

0.00

0.00

0.00

CONTRACTUAL SERVICES

377.00

0.00

377.00

EQUIPMENT

55,829.17

0.00

55,829.17

OTHER DIRECT COSTS

416.32

0.00

416.32

INDIRECT COSTS

0.00

0.00

0.00

TOTAL REIMBURSABLE AGENCY COSTS

$$$

105,873.06

0.00

105,873.06

I CERTIFY that I am duly appointed and acting officer of the herein named agency; that the costs being claimed herein are in all respects true, correct, and in accordance with the contract provisions; that funds were expended or obligated during the grant period; and the net amount claimed above has not been previously presented to or reimbursed through the Office of Traffic Safety.

SUBMITTED BY:

John K. Smith

TITLE:

Chief of Police

(Type Name and Title: Grant Director/Authorizing Official/Fiscal Official as listed on the Grant Agreement)

SIGNATURE:

DATED:

PREPARED BY:

Sgt. Donald Dunn

Telephone No.: 555-555-3232

(Print or Type Name)

E-Mail: Ddunn@anytown.org

OTS USE ONLY QPR: TC: FFY: VDR #: Reviewed By: Dated:
OTS USE ONLY
QPR:
TC:
FFY:
VDR #:
Reviewed By:
Dated:

STATE OF CALIFORNIA OFFICE OF TRAFFIC SAFETY

 

GRANT CLAIM DETAIL

 

EXHIBIT 5-A

Agency

City of Anytown

Grant No.

PT1099

Claim No.

2

Period of Incurred Costs

January 1, 2010

Thru

March 31, 2010

Personnel Costs:

Salaried Positions

Officer

Overtime

Salary Cost

12,582.00

Overtime Cost

Salary Benefits

4,768.57

Overtime Benefits

Total Claimed

17,350.57

0.00

0.00

0.00

0.00

0.00

0.00

0.00

DUI/DL Checkpoints

24,000.00

2,400.00

26,400.00

Special Enforcement Operations

5,000.00

500.00

5,500.00

 

0.00

 

0.00

 

0.00

 

0.00

 

0.00

 

0.00

Subtotals

41,582.00

7,668.57

Travel Expenses:

Name of Traveler

Total Personnel Costs:

Purpose of Travel

Destination

(OTS Summit, etc.)

(City,State)

Date(s)

Total Travel Expenses:

$ 49,250.57

$ 0.00

Contractual Services:

Contractor(s) Phlebotomist Services - ACP Blood Draw 377.00 Total Contractual Services: $ 377.00 Equipment: Invoiced
Contractor(s)
Phlebotomist Services - ACP Blood Draw
377.00
Total Contractual Services:
$
377.00
Equipment: Invoiced Amount (Attach Invoices and Equipment Report OTS-25)
Item(s) Purchased
(1) DUI Trailer
20,662.50
(1) Motorcycle
21,127.37
(1) Radar Trailer
14,039.30
Total Equipment Costs:
$
55,829.17
Other Direct Costs:
Item(s) Purchased/Charged
Educational Materials
254.67
Office Supplies
35.09
Printing/Duplication
Communications
126.56
Total Other Direct Costs:
$
416.32
Indirect Costs:
Approved Personnel Rate:
0.00%
x$
49,250.57 (Total Personnel Costs)
$
0.00
OR
Approved Contractual Rate:
0.00%
x$
377.00
(Total Contractual Costs)
$
0.00
Total Indirect Costs:
$
0.00
TOTAL AMOUNT CLAIMED:
$
105,873.06
State of California • Office of Traffic Safety EQUIPMENT REPORT OTS-25 (Rev 11/08) Agency: CITY
State of California • Office of Traffic Safety
EQUIPMENT REPORT
OTS-25 (Rev 11/08)
Agency:
CITY OF ANYTOWN
Grant #:
PT1099
DUI AND SEAT BELT PROGRAM
10/1/09
Grant
9/30/11
Grant Title:
Grant Start:
End:
OTS-25 (Rev. 6/09)
1.Equip.
2. Date
3.
Item Manufacturer and
4.
Model and Year
5. Identification Number
(Serial #, VIN, ID#, etc.)
6. Total Federal
Funds
7.
Location of
8. Current
#
Received
Description
Equipment
Fair
Market
Value
2/8/10
DUI TRAILER
2009
4TRL45604506
20,662.50
20,662.50
3/15/10
MOTORCYCLE
2009 Harley Davidson
76HD458Y0321
21,127.37
Anytown Police
Department, 2700 Main
Street, Anytown, CA
21,127.37
90001
3/29/10
RADAR TRAILER
2009
99HPT5369725
14,039.30
"
14,039.30
"
9. Describe method for determining current fair market value: NEW – PURCHASE PRICE.
10. I hereby certify that the information above is complete and accurate to the best of my knowledge, and that all conditions set forth in DOT Common Rule and 49 CFR 18.32 are being complied with.
FISCAL/ACCOUNTING OFFICIAL Fred T. Carter
SIGNATURE
Phone Number:555-555-4712 DATE
GRANT DIRECTOR John K Smith
SIGNATURE
Phone Number:555-555-2711 DATE
11. If equipment value listed above is less than $5,000, no additional information will be needed in the future. If value is $5,000 or more, what will the equipment be used for? (Check one box.)
Continuing with the same purpose though not federally sponsored.
OTS/Other Federal Grant (Provide Grant # and Name.)
Equipment cannot be used on any Federal grant but will be retained or sold by the agency, and current market value multiplied by the percentage originally funded will be refunded to OTS.
Contact OTS for instructions.
Equipment will be returned to OTS for use on other OTS grants. Contact OTS for instructions.
FISCAL/ACCOUNTING OFFICIAL
SIGNATURE
Phone Number:
DATE
GRANT DIRECTOR
SIGNATURE
Phone Number:
DATE:
(To be completed by OTS)

Anytown Equipment Company Address Address Phone number

 

INVOICE

DATE

To:

Ship To:

 

City of Anytown Accounts Payable 2700 Main Street Anytown, CA 90001

 

Anytown Police Department 2700 Main Street Anytown, CA 90001

 

Salesperson

PO

Requisitioner

Shipped

FOB Point

Terms

Number

 

VIA

Cecil

0888990

Sgt. Donald

Vendor

Corp Yard

Net 5

Dunn

Direct

Quantity

 

Description

 

Unit Price

 

Amount

1

 

2009 Equipment Trailer VIN 4TRL45604506

     

19,000.00

   

Sales Tax

 

$1,662.50

TOTAL

$20,662.50

Anytown Harley Davidson Company Address Address Phone number

 

INVOICE

DATE

To:

Ship To:

 

City of Anytown Accounts Payable 2700 Main Street Anytown, CA 90001

 

Anytown Police Department 2700 Main Street Anytown, CA 90001

 

Salesperson

 

PO

Requisitioner

Shipped

FOB Point

Terms

 
 

Number

 

VIA

David

 

045590

Sgt. Donald

Vendor

Corp Yard

Net 20

 

Dunn

Direct

Quantity

 

Description

 

Unit Price

Amount

 

1

 

2009 Harley Davidson VIN 76HD458Y0321

 

17,438.47

17,438.47

1

Super Mic

699.00

699.00

2

Motorcycle Cable Kit

 

645.00

1,290.00

   

Sales Tax

$1,699.90

TOTAL

$21,127.37

Anytown Radar Company Address Address Phone number

 

INVOICE

 

DATE

 

To:

Ship To:

 

City of Anytown Accounts Payable 2700 Main Street Anytown, CA 90001

 

Anytown Police Department 2700 Main Street Anytown, CA 90001

 

Salesperson

PO

Requisitioner

Shipped

FOB

 

Terms

 

Number

VIA

Point

 

Jeff

3598890

Sgt. Donald

Vendor

Corp Yard

 

Net 5

Dunn

Direct

 

Quantity

 

Description

 

Unit Price

   

Amount

1

 

2009 Radar Trailer VIN 99HPT5369725

 

14,900.00

   

12,197.00

   

Sales Tax S & H TOTAL

   

$1,067.24

$775.06

$14,039.30