TRANSP FUND FOR CLEAN AIR - FY 2012/13

ALAMEDA COUNTY TRANSPORTATION COMMISSION TRANSPORTATION FUND FOR CLEAN AIR (TFCA) PROGRAM REQUEST FOR REIMBURSEMENT OF FUNDS FY 2012/2013 Project Sponsor: City of Pleasanton TFCA Project ID: 12-ALA-02 Project Title: Pleasanton Trip Reduction Program Total TFCA funds •ro•rammed to project: $ Amount of funds re.uested for reimbursement: $ Total of •revious reimbursements: $ Remainin• balance after this reimbursement: $ To the best of my knowledge, the above information is true and correct and I am authorized to request this reimbursement of funds. Name and Title: Signature: Date: IMPORTANT! Please attach supporting documentation for all items for which you are seeking reimbursement. All reimbursements will be limited to TFCA eligible costs that are consistent with the project scope in Appendix A of the TFCA agreement. Reimbursement requests without complete supporting documentation for all items, such as copies of invoices, copies of checks as proof of payment, or detailed timesheets as proof of incurred costs for labor, will be returned to the sponsor. This section is reserved for Alameda CTC use: Alameda CTC approval: Alameda CTC accounting Project ID: Amount Paid: Fund type(G/D): _ Check Number: Amount: Date Paid: Approvals: Initials Date Initials: Preparer: Responsible Program Manager: _ Deputy Director: Director of Finance: