HomeMy WebLinkAbout23-007 David Wellhouse & Associates for Annual State Mandated Cost Claiming Services (2024-2025)State of California
State Controller's Office Mandated Cost Manual for Local Agencies
DOMESTIC VIOLENCE ARREST For State Controller Use Only
Program
POLICIES AND STANDARDS (19) Program Number 00167
CLAIM FOR PAYMENT FORM (20) Date Filed 167
(2 1) LRS Input
(01) Claimant Identification Number 9843231 Reimbursement Claim Data
(02) Claimant Name City of Cupertino (22) FORM 1, (04) (a) 45
County of Location Santa Clara (23) FORM 1, (04) (b) 305.35
Street Address or P.O. Box and Suite 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 @ (27) FORM 1, (07) C. (g)
(05) (10) Combined (28) FORM 1 , (09) 0
(06) (11) Amended (29) FORM 1, (10)
(07 ) (12) Fiscal Year of Cost 2024/2025 (30) FORM 1 , (1 2)
(08) (13) Total Claimed Amount $6 ,596 (31) FORM 1 , (13)
(14) Less: 10% Late Penalty (32)
(15) Less: Prior Claim Payment Received (33)
(16) Net Claimed Amount $6,596 (34)
(17) Due from State $6,596 (35)
(18) Due to State (36)
(37) C ERTIFICATION 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 Governm ent Code.
I further certify that there was no application othe r 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. A ll 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.
.,,,J
Signature of Authorized Officer Date Signed
X I Telephone Number (408) 777-3225
Type or Print Name and Title of Authorized Signatory Email Add ress kirstens@cui2ertino .gov
Kirsten Squarcia, Deputy City Manager
(38) Name of Agency Contact Person for Cla im Telephone Number
I Email Address
Name of Consulting Firm/Claim Preparer Te lepho ne Number (916) 797-4883 --
David Wellhouse & Associates, Inc Email Address dwa-renee@su rewest. net
Revised 10/2025
Interim
2/11/26
State of California
State Controller's Office Mandated Cost Manual for Local Agencies
DOMESTIC VIOLENCE ARRESTS AND VICTIM For State Controller Use Only
ASSISTANCE 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)4,580
(03)Type of Claim (26)FORM 1, (06)0
(04)(09) Reimbursement 0 (27)FORM 1, (07)
(-05}3 ,. (10) Combined (28)FORM 1, (09)
(06)( 11) Amended (29)FORM 1, (10)
(07)(12) Fiscal Year of Cost 2024/2025 (30)
(08)(13) Total Claimed Amount $4,580 (31)
(14)Less: 10% Late Penalty (32)
(15)Less: Prior Claim Payment Received (33)
(16)Net Claimed Amount $4,580 (34)
(17)Due from State $4,580 (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
cif'fhe 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� � .J ---I Telephone Number (408) 777-3225
�-; � ./-/ Email Address kirstens@cuQertino.gov Type or Print Name and fitle of Authorized Signatory
Kirsten Squarcia, Interim Deputy City Manager
(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
I ��vised 10/2025
2/11/26
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 Number 00246 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 2024/2025 (30)
(08)(13) Total Claimed Amount $2,061 (31)
(14)Less: 10% Late Penalty (32)
(15)Less: Prior Claim Payment Received (33)
(16) Net Claimed Amount $2,061 (34)
(17)Due from State $2,061 (35)
(18)Due to State (36)
(37)CERTIFICATION OF CLAIM
In accord.ance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officer
au'fn·onzed 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
a\tachectstatements.
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
X � _-;fz_ ./Lt' -' I-
Type or Print Name and'Title of Authorized Signatory
Kirsten Squarcia, Interim Deputy City Manager
(38)Name of Agency Contact Person for Claim I Name of Consulting Firm/Claim Preparer
David Wellhouse & Associates, Inc
Revised 10/2025
Date Signed
Telephone Number
Email Address
Telephone Number
Email Address
Telephone Number
Email Address
(408)777-3225
kirstens@cui;1ertino.gov
(916)797-4883
dwa-renee@su rewest. net
2/11/26
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 00187
CLAIM FOR PAYMENT FORM (20) Date Filed 187 (21)LRS Input(01)Claimant Identification Number 9843231 Reimbursement Claim Data (02)Claimant Name City of Cupertino (22)FORM 1, (04)34 County of Location Santa Clara (23)FORM 1, (05)2,059 Street Address or P.O. Box and Suite 10300 Torre Avenue (24)FORM 1, (06)(A)(g)City, State, and Zip Code Cupertino, CA 95014 (25)FORM 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)(10) Combined (28)FORM 1, (08)(06)(11) Amended (29)FORM 1, (09)(07)(12) Fiscal Year of Cost 2024/2025 (30)FORM 1, (11)(08)(13) Total Claimed Amount $1,944 (31)FORM 1, (12)(14)Less: 10% Late Penalty (32)(15)Less: Prior Claim Payment Received (33)(16)Net Claimed Amount $1,944 (34)( 17)Due from State $1,944 (35) (18)Due to State (36) (37)CERTIFICATION OF CLAIMIn accordance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officerauthorized by the local agency to file mandated cost claims with the State of California for this program, and certifyunder penalty of perjury that I have not violated any of the provisions of Article 4, Chapter 1 of Division 4 of Title 1 ofthe 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 � -�L k -I Telephone Number (408) 777-3225---
Type or Print Name and 'Title of Authorized Signatory Email Address kirstens@cugertino.gov
Kirsten Squarcia, Deputy City Manager
(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 10/2025
Interim
2/11/26
State of California
State Controller's Office Mandated Cost Manual for Local Agencies
For State Controller Use Only Program RACIAL AND IDENTITY PROFILING ( 19)Program Number 00375
CLAIM FOR PAYMENT FORM (20)Date Filed 375 (21)LRS Input
(01)Claimant Identification Number 9843231 Reimbursement Claim Data
(02)Claimant 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)2,281
(03)Type of Claim (26)FORM 1, (04) B. 3. (f)0
(04)(09) Reimbursement Ill (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 2024/2025 (30)FORM 1, (07)
(08)(13) Total Claimed Amount $2,281 (31)FORM 1, (09)0
(14)Less: 10% Late Penalty (32)FORM1,(10)0
(15)Less: Prior Claim Payment Received (33)
(16)Net Claimed Amount $2,281 (34)
( 17)Due from State $2,281 (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.
'fhe-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
X 0.--� ·y1;-h ---' I-
Type or Print Name ancfTille of Authorized Signatory
Kir.sten Squarcia, Interim Deputy City Manager
(38)Name of Agency Contact Person for Claim
Name of Consulting Firm/Claim Preparer
David Wellhouse & Associates, Inc
Revised 10/2025
I
Date Signed
Telephone Number {408) 777-3225
Email Address kirstens@cuQertino.gov
Telephone Number
Email Address
Telephone Number (916)797-4883
Email Address dwa-renee@su rewest. net
2/11/26