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APPENDIX B <br /> REQUEST FOR REIMBURSEMENT OF FUNDS <br /> SAMPLE FORM <br /> (Submit Requests on SPONSOR letterhead) <br /> Project SPONSOR: <br /> Project Title: <br /> RM2 Project: The Eastbound I-580 Landscape Replacement Project in the Tri-Valley <br /> Total RM2 funds programmed to the PROJECT: $ 138,358 <br /> Total of previous reimbursement requests: $ <br /> Balance available for this request: $ <br /> Amount of this Request *: $ _ <br /> * Supporting documentation must be submitted for expenditures to be reimbursed. Copies of executed <br /> contracts or agreements for which reimbursement is requested must be submitted prior to ACCMA <br /> approval of reimbursement. Costs should be segregated by the Cost Line Items shown in Table Al in <br /> Appendix A. If there are matching fund requirements stipulated in Appendix B, supporting <br /> documentation is required for both costs to be reimbursed by the RM2 and costs to be funded by <br /> matching funds. <br /> To the best of my knowledge, the above information is true and correct and I am authorized to request this <br /> reimbursement of funds. <br /> Name &Title: <br /> Signature: Date: <br /> Attachments <br />