Vermont Agency of Transportation Monthly Expense Invoice, Report, & Request for Reimbursement sample: 06GR01 Transit Provider: full title x Grant #: for Month of: x Year: 2006 GENERAL INSTRUCTIONS: fill in yellow, green, and blue fields. (X ed fields) Elders and Persons with Disabilities Program EA/Subjob #: x for Month of: 0 Van Service $ x Volunteer Reimbursement $ x Taxi Reimbursement $ x In-Kind Volunteer applied $ x OTHER $ x Net Total* (100%) Requested from VTrans (80%) Local Match (20%) # of In-Kind Hours x $ $ $ 0 X 7.00 = $ x x x -
A copy of the service indicator report must accompany this request for reimbursement for the Elders and Persons with Disabilities Program. A certified copy of the AHS FY 07 5311 E&D Program Annual Summary updated monthly and the AHS FY 07 5311 E&D 2-Page Regional Statistical Summary Monthly reports must accompany this request for reimbursement for the Elders and Persons with Disabilities Program. Rural PM Program EA/Subjob #: x for Month of: 0 Net Total (100%) Requested from VTrans (80%) Local Match (20%) $ $ $ x x x
Total Due: $
-
I certify, under penalties of perjury that these expenses and the accompanying service data are accurate. The subsidy requested is a proper charge to the Grant Number 0 and the above referenced Expense Accounts (EA/Subjob#s), between the Vermont Agency of Transportation and the Public Transit Provider, 0 . Organization: Address: Telephone Number: Name and Title: Notes: x 0 x x x
Signature:
DATE:
03/04/09
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S. 5311 & CMAQ MONTHLY SERVICE INDICATOR REPORT
AGENCY: FISCAL YEAR: JULY SERVICE DAYS VEHICLE HOURS REVENUE VEHICLE HOURS VEHICLE MILES REVENUE VEHICLE MILES # RIDES AUGUST SEPT OCT NOV Route Name:
DEC
JAN
FEB
MAR
APRIL
MAY
JUNE
TOTAL 0 0 0 0 0 0
COSTS MEASURES TOTAL COST COST PER MILE COST PER HOUR COST PER PASSENGER $0 #DIV/0! #DIV/0! #DIV/0!
RIDERSHIP MEASURES # OF BOARDINGS BOARDINGS PER VEHICLE HOUR BOARDINGS PER VEHICLE MILE BOARDINGS PER SERVICE DAY 0 0 0 0 0 0 0 0 0 0 0 0 #DIV/0! #DIV/0! #DIV/0! 0
FARES COLLECTED FARE BOX/TOTAL COST FARE PER PASSENGER MILES/SERVICE DAY HOURS/SVC DAY PERCENT REVENUE HOURS PERCENT REVENUE MILES
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
S. 5311 & CMAQ QUARTERLY SERVICE INDICATOR REPORT
AGENCY: FISCAL YEAR: JULY - SEPTEMBER SERVICE DAYS VEHICLE HOURS REVENUE VEHICLE HOURS VEHICLE MILES REVENUE VEHICLE MILES # RIDES OCTOBER - DECEMBER Route Name:
JANUARY - MARCH
APRIL - JUNE
TOTAL 0 0 0 0 0 0
COSTS MEASURES TOTAL COST COST PER MILE COST PER HOUR COST PER PASSENGER #DIV/0! #DIV/0! #DIV/0! $0
RIDERSHIP MEASURES # OF BOARDINGS BOARDINGS PER VEHICLE HOUR BOARDINGS PER VEHICLE MILE BOARDINGS PER SERVICE DAY 0 0 0 0 #DIV/0! #DIV/0! #DIV/0! 0
FARES COLLECTED FARE BOX/TOTAL COST FARE PER PASSENGER MILES/SERVICE DAY HOURS/SVC DAY PERCENT REVENUE HOURS PERCENT REVENUE MILES
$0
$0
$0
$0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
$0