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23-007 David Wellhouse and Associates for 2025 State Mandated Cost Reimbursement Claims (FY 23-24) _021325State of California State Con t roller 's Office Mandated Cost Manual for Local Agencies DOMESTIC VIOLENCE ARREST For State Controller Use Only POLICIES AND STANDARDS (19) Program Number 0016 7 Program CLAIM FOR PAYMENT FORM (20) Date Filed 167 (21) LRS Input (01) Claimant Identification Number 9843231 Reimbursement Claim Data (02) Claimant Name City of Cupertino (22) FORM 1, (04) (a) 50 County of Location Santa Clara (23) FORM 1 , (04) (b) 280.71 Street Address or P.O . Box and Su ite 10300 Torre Avenue (24) FORM 1 , (06) City , State , and Zip Code Cupertino, CA 95014 (25) FORM 1, (07) A. (g) (03) Type of Claim (26) FORM 1, (07) B. (g) (04) (09) Reimbursement 0 (27) FORM 1 , (07) C . (g) (05) (10) Combined (28) FORM 1 , (09) 0 (06) ( 11) Amended (29) FORM1,(10) (07) (12) Fiscal Year of Cost 2023/2024 (30) FORM 1 , (12) (08) (13) Total Claimed Amount $6,737 (31) FORM1 ,(13) (14) Less : 10% Late Penalty (32) (15) Less : Prior Claim Payment Received (33) (16) Net Claimed Amount $6,737 (34) (17) Due from State $6,737 (35) (i 8) Due to State (36) (37) CERTIFICATION OF CLAIM In accordance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officer authorized by the local agency to file mandated cost claims with the State of California for this program , and certify under penalty of perjury that I have not violated any of the provisions of Article 4 , Chapter 1 of Division 4 of Title 1 of the Government Code . I further certify that there was no application other than from the claimant , nor any grant(s) or payment(s) received for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of seNices of an existing program . All offsetting revenues and reimbursements set forth in the parameters and guidelines are identified, and all costs claimed are supported by source documentation currently maintained by the claimant. The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the attached statements. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature of Authorized Officer Date Signed X ~ ,J ---, I Telephone Number (408) 777-3225 ' / / -----'- Type or Print Name and Title--6 f Authorized Signatory Email Address k irstens@cugertino .org Kirsten Squarcia, City Clerk (38) Name of Agency Contact Person for Claim Telephone Number I Email Address Name of Consulting Firm/Claim Prepar er Telephone Number (916) 797-4883 David Wellhouse & Associates, Inc Email Address dwa-renee@surewest.net Revised 10/2024 State of California State Controller's Office Mandated Cost Manual for Local Agencies DOMESTIC V IOLENCE ARRESTS AND VICTIM For State Controller Use Only ASS ISTANCE CLAIM FOR PAYMENT FORM (19) Program Number 00274 Program (20) Date Filed 274 (21) LRS Input (01) Claimant Identification Number 9843231 Reimbursement Claim Data (02) Claimant Name City of Cupertino (22) FORM 1 , (04) A. 1. (f) County of Location Santa Clara (23) FORM 1, (04) A. 2 . (f) Street Address or P.O. Box and Suite 10300 Torre Avenue (24) FORM 1, (04) A. 3 . (f) City, State, and Zip Code Cupertino, CA 95014 (25) FORM 1, (04) B . 1 (f) 4,679 (03) Type of Claim (26) FORM 1, (06) 0 (04) (09) Reimbursement 0 (27) FORM 1, (07) (05) (10) Combined (28) FORM 1, (09) (06) (11) Amended (29) FORM 1 , (10) (07) (12) Fiscal Year of Cost 2023/2024 (30) (08) (13) Total Claimed Amount $4,679 (31) (14) Less : 10% Late Penalty (32) (15) Less : Prior Claim Payment Received (33) (16) Net Claimed Amount $4,679 (34) (17) Due from State $4,679 (35) (18) Due to State (36) (37) CERTIFICATION OF CLAIM In accordance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officer authorized by the local agency to file mandated cost claims with the State of California for this program , and certify under penalty of perjury that I have not violated any of the provisions of Article 4 , Chapter 1 of Division 4 of Title 1 of the Government Code . I further certify that there was no application other than from the claimant, nor any grant(s) or payment(s) received for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of services of an existing program . All offsetting revenues and reimbursements set forth in the parameters and guide lines are identified , and all costs claimed are supported by source documentation currently maintained by the claimant. The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the attached statements . I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature of Authorized Officer Date Signed X ~A -b ~ '-I Telephone Number (408) 777-3225 ./7/J -r Type or Print Name and Titre' of Authorize.ct Signatory Email Address kirstensC@.cu12ertino . org Kirsten Squarcia, City Clerk (38) Name of Agency Contact Person for Cla im Telephone Number I Email Address Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883 David Wellhouse & Associates, Inc Email Address dwa-re·n ee(@su rewest.net Revised 10/2024 State of California State Controller's Office Mandated Cost Manual for Local Agencies ADMINISTRATIVE LICENSE For State Controller Use Only SUSPENSION -PER SE (19) Program Numb e r 00 246 Program CLAIM FOR PAYMENT FORM (20) Date Filed 246 (21) LRS Input (01) Claimant Identification Number 9843231 Reimbursement Claim Data (02) Claimant Name City of Cupertino (22) FORM 1, (04) A 1. (h) County of Location Santa Clara (23) FORM 1, (04) A 2 . (h) Street Address or P.O. Box and Suite 10300 Torre Avenue (24) FORM 1, (04) B. 1. (h) 2,248 City, State , and Zip Code Cupertino, CA 95014 (25) FORM 1 , (06) 0 (03) Type of Claim (26) FORM 1, (07) (04) (09) Reimbursement 0 (27) FORM 1, (09) (05) (10) Combined (28) FORM 1, (10) (06) (11) Amended (29) (07) (12) Fiscal Year of Cost 2023/2024 (30) (08) (13) Total Claimed Amount $2,316 (31) (14) Less: 10% Late Penalty (32) (15) Less: Prior Claim Payment Received (33) (16) Net Claimed Amount $2,316 (34) (17) Due from State $2,316 (35) (18) Due to State (36) (37) CERTIFICATION OF CLAIM In accordance with the provisions of Government Code sections 17560 and 17561 , I certify that I am the officer authorized by the local agency to file mandated cost claims with the State of California for this program , and certify under penalty of perjury that I have not violated any of the provisions of Article 4, Chapter 1 of Division 4 of Title 1 of the Government Code . I further certify that there was no application other than from the claimant , nor any grant(s) or payment(s) received for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of services of an existing program . All offsetting revenues and reimbursements set forth in the parameters and guidelines are identified , and all costs claimed are supported by source documentation currently maintained by the claimant. The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the attached statements . I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature of Authorized Officer Date Signed X ~~ jA iA .; -I Telephone Number (408) 777-3225 ..., -, I -- Type or Print Name and T(t(e of Authorized Signatory Email Address ki rstens@cut;1ert ino .org Kirsten Squarcia, City Clerk (38) Name of Agency Contact Person for Claim Telephone Number I Email Address Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883 David Wellhouse & Associates, Inc Email Address dwa-renee(@surewest.net Revised 10/2024 State of California State Controller's Office Mandated Cost Manual for Local Agencies PEACE OFFICERS For State Controller Use Only Program PROCEDURAL BILL OF RIGHTS (19) Program Number 001 87 CLA IM FOR PAYMENT FORM (20) Date Filed 187 (21) LRS Input (01) Claimant Identification Number · 9843231 Reimbursement C laim Data (02) Cla imant Name City of Cupertino (22) FO RM 1 , (04) 34 County of Locati on Santa C lara (23) FO RM 1 , (05) 2,059 Street Address or P.O. Bo x and Suite 10300 Torre Avenue (24) F ORM 1, (06)(A)(g) City, State, an d Zip Code Cupertino, CA 95014 (25) FO RM 1, (06)(B)(g) (03) Type of Claim (26) FORM 1, (06)(C)(g) (04) (09) Reimbursement 0 (27) FORM 1, (06)(D)(g) (05) (1 0) Combined (28) FORM 1, (08) (06) (1 1) Amende d (29) FO RM 1 , (09) (07) (12) Fisca l Year of Cost 2023 /2024 (3 0) FO RM 1 , (11) (08) (13) T otal Claimed Amount $1,930 (31) FO RM 1, (12) (14) Less : 10% Late Penalty (32) (15) Less : Prior Claim Payment Received (33) (16) Net Claimed Amount $1,930 (34) (17) Due from State $1,930 (35) (18) Due to State (36) (37) CERTIFICATION OF CLAIM In accordance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officer authorized by the local agency to file mandated cost claims with the State of Ca lifornia for this program , and certify under penalty of perjury that I have not violated any of the provisions of Article 4, Chapter 1 of Division 4 of Title 1 of the Government Code. I further certify that there was no app li cat ion other than from the c laimant, nor any grant(s) or payment(s) rece ived for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of services of an existing program . All offsetting revenues and reimbursements set forth in the parameters and guidelines are identified , and all costs claimed are supported by source documentation currently maintained by the claimant. The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the attached statements . I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature of Authorized Officer Date Signed X ~>A J_ -'-~--~1 Telephone Number (408) 777-3225 ---"'-7 ·1 Type or Pr int Name and Titl ~of Authorized Signatory Email Address kirstens@cuRertino .org Kirsten Squarcia, City Clerk (38) Name of Agency Contact Person for Claim Te lephone Number I Emai l Address Name of Consulting Firm/Cla im Preparer Telephone Number (916) 797-4883 David Wellhouse & Associates, Inc Email Address dwa-renee@su rewest. net Revised 10/2024 State of California State Controller's Office Mandated Cost Manual for Local Agencies For State Controller Use Only Program RACIAL AND IDENTITY PROF ILING (19) Program Numbe r 00375 CLAIM FOR PAYMENT FORM (20) Date Filed 375 (21) LRS Input (01) Claimant Identification Number 9843231 Reimbursement Claim Data (02) C laimant Name City of Cupertino (22) FORM 1, (04) A 1. (f) 0 County of Location Santa Clara (23) FORM 1 , (04) A 2. (f) 0 Street Address or P.O. Box and Suite 10300 Torre Avenue (24) FORM 1, (04) B. 1. (f) 0 City, State, and Zip Code Cupertino, CA 95014 (25) FORM 1, (04) B. 2. (f) 23,953 (03) Type of Claim (26) FORM 1, (04) B. 3. (f) 0 (04) (09) Reimbursement 0 (27) FORM 1, (04) B. 4 . (f) 0 (05) (10) Combined (28) FORM 1, (04) B. 5. (f) 0 (06) ( 11) Amended (29) FORM 1, (06) 0 (07) (12) Fiscal Year of Cost 2023/2024 (30) FORM 1, (07) (08) (13) Total Claimed Amount $23,953 (31) FORM 1, (09) 0 (14) Less: 10% Late Penalty (32) FORM 1 , (10) 0 (15) Less : Prior Claim Payment Received (33) (16) Net Claimed Amount $23,953 (34) ( 17) Due from State $23,953 (35) (18) Due to State (36) (37) CERTIFICATION OF CLAIM In accordance with the provisions of Government Code sections 17560 and 17561 , I certify that I am the officer authorized by the local agency to file mandated cost claims with the State of California for this program , and certify under penalty of perjury that I have not violated any of the provisions of Article 4 , Chapter 1 of Division 4 of Title 1 of the Government Code. I further certify that there was no application other than from the claimant , nor any grant(s) or payment(s) received for reimbursement of costs claimed herein and claimed costs are for a new program or increased leve l of services of an existing program . All offsetting revenues and reimbursements set forth in the parameters and guidel ines are identified , and all costs claimed are supported by source documentation currently maintained by the claimant. The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the attached statements . I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature of Authorized Officer Date Signed X ~ /2 J, ~ ' _I Telephone Number (408) 777-3225 4 Type or Print Name and Ti~1of Authorized Signatory Email Address kirstens@cuQert i no.org Kirsten Squarcia, City Clerk (38) Name of Agency Contact Person for Claim Telephone Number I Email Address Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883 David Wellhouse & Associates, Inc Email Address dwa-renee©.su rewest. net Revised 10/2024