Agency Information

EXHIBIT 5-A
Agency Name: Must match the
Grant Agreement, Page 1, Box 2
(OTS-38)
Agency Name: City of Anytown

Office Authorized to Receive Payments: City Treasurer

This is the office or Address 1: 2700 Main Street
department that
reimbursement checks Address 2: Anytown, CA 90001
Address: Must match the Grant
should be made payable to
Address 3: Agreement, Page 1, Section D.
and should match the Grant
Agreement, Page 1 Section
D. (OTS-38)
(Cannot be an individual's Grant Number: PT1099
name)

Grant Start Date: 10/1/2009

Personnel Indirect Rate: 0.00%

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

Contractual Services Indirect Rate: 0.00%

 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

2208 Kausen Drive, Ste 300
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 LESS PRIOR NET AMOUNT

TO DATE CLAIMS 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-39 (Rev. 8/09)

 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 Salary Cost Salary Benefits Total Claimed
Officer 12,582.00 4,768.57 17,350.57
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Overtime Overtime Cost Overtime Benefits
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

Total Personnel Costs: $ 49,250.57

Travel Expenses:
Purpose of Travel Destination
Name of Traveler Date(s)
(OTS Summit, etc.) (City,State)

Total Travel Expenses: $ 0.00

OTS-39a (Rev. 9/08) Page 1 of 2

Contractual Services:
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

OTS-39a (Rev. 9/08) Page 2 of 2

 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 6. Total Federal 7. Location of 8. Current
# Received Description (Serial #, VIN, ID#, etc.) Funds Equipment Fair
Market
Value
2/8/10 DUI TRAILER 2009 4TRL45604506 20,662.50 Anytown Police 20,662.50
Department, 2700 Main
(To be completed by OTS)

3/15/10 MOTORCYCLE 2009 Harley Davidson 76HD458Y0321 21,127.37 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: _________________

Anytown Equipment Company INVOICE
Address DATE
Address
Phone number

To: Ship To:

City of Anytown Anytown Police Department
Accounts Payable 2700 Main Street
2700 Main Street Anytown, CA 90001
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 19,000.00
VIN 4TRL45604506

Sales Tax $1,662.50

TOTAL $20,662.50
Anytown Harley Davidson Company INVOICE
Address DATE
Address
Phone number

To: Ship To:

City of Anytown Anytown Police Department
Accounts Payable 2700 Main Street
2700 Main Street Anytown, CA 90001
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 17,438.47 17,438.47
VIN 76HD458Y0321

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 INVOICE
Address DATE
Address
Phone number

To: Ship To:

City of Anytown Anytown Police Department
Accounts Payable 2700 Main Street
2700 Main Street Anytown, CA 90001
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 14,900.00 12,197.00
VIN 99HPT5369725

Sales Tax $1,067.24

S&H $775.06
TOTAL $14,039.30