HomeMy WebLinkAbout14-181 David Wellhouse & Associates, Inc._Claim Reimbursement sheets for FY 2013-2014*,//David Wellhouse
...and Associates, Inc.
March 16, 2015
Ms. Grace Schmidt
City Clerk
City of Cupertino
10300 Torre Avenue
Cupertino, California 95014
RE: COPIES OF FEBRUARY 2015 STATE MANDATED COST REIMBURSEMENT CLAIMS:
Dear Ms. Schmidt:
Enclosed are the copies of the February 2015 state mandated cost reimbursement claims prepared on behalf
of the City of Cupertino by David Wellhouse & Associates, Inc..
I would like to especially thank you and the City staff for the support, experience, and professionalism
extended to me throughout this process. In this field, the optimization of the state mandated cost
reimbursement process is directly influenced by a good working relationship and the support extended by
City staff.
Thank you again for selecting David Wellhouse & Associates to fulfill your state mandated cost claiming
needs. As always, I have very much enjoyed working with you and hope to assist the City of Cupertino
for many years to come.
In the next few days, you should receive an invoice for our services for the preparation and filing of the
February 2015 state mandated cost reimbursement claims. Should you have any questions, please contact
me at (916) 797-4883.
Si ely,
enee Wellhouse
Enclosures
3609 Bradshaw Road, Suite H-382 • Sacramento, California 95827
(916) 797-4883 • FAX (916) 797-4887
iii David Welffiouse
...and Associates, Inc.
STATE MANDATED COST CLAIMS RECEIPT
FEBRUARY 2015 STATE MANDATED COST CLAIMS
AGENCY: CITY OF CUPERTINO
DATE: FEBRUARY 17, 2015
The State Controller's Office, Division of Accounting, Local Reimbursement Bureau hereby
acknowledges receipt of the following State Mandated Cost Claims (SB 90) prepared and
submitted on behalf of the above -noted agency by David Wellhouse & Associates, Inc.
CHAPTER
CLAIM PERIOD
AMOUNT
Chapter 256, Statutes of 1995
FY. 2013/2014 Actual
$6,664
Domestic Violence Arrest Standards
Chapter 698 & 702, Statutes of 1998
FY. 2013/2014 Actual
$2,777
Domestic Violence Arrest & Victim Assistance
Chapter 1460, Statutes of 1989
FY. 2013/2014 Actual
$7,705
Administrative License Suspension
Chapter 465, Statutes of 1976
FY. 2013/2014 Actual
$1,309
Peace Officers Procedural Bill of Rt'g'iats
Chapter.630, Statutes of 1978
FY. 2013/2014 Actual
Peace Officer's Personnel Records
Chapter 999, Statutes of 1991 FY. 2013/2014 Actual
Rape Victim Counseling Center Notices
Chapter 901, Statutes of 2000 FY. 2012/2013 Actual
Local Government Employee Relations
Chapter 1120, Statutes of 1996 FY. 201312014 Actual
Health Benefits for Survivors of Police & Fire
Chapter982, Statutes of 2000 & 2001 FY. 2013/2014 Actual $11,427
California Public Records Act
FEB 17 2015 1ri
STATE CONTROLLER'S OFFICE
DIV. OF ACCOI.Iid I�iG & REPORTING
Received By:
State Controller's Office
Division of Accounting & Reporting
Local Reimbursement Bureau
i David Wellhouse
...and Associates, Inc.
STATE MANDATED COST CLAIMS RECEIPT
FEBRUARY 2013 STATE MANDATED COST CLAIMS
AGENCY: CITY OF CUPERTINO
DATE: FEBRUARY 15, 2015
The State Controller's Office, Division of Accounting, Local Reimbursement Bureau hereby
acknowledges receipt of the following State Mandated Cost Claims (SB 90) prepared and
submitted on behalf of the above -noted agency by David Wellhouse & Associates, Inc.
CHAPTER CLAIM PERIOD AMOUNT
Chapter 256, Statutes of 1995 FY. 2012/2013 Late Actual
Domestic Violence Arrest Standards
Chapter 698 & 702, Statutes of 1998 FY. 2012/2013 Late Actual
Domestic Violence Arrest & Victim Assistance
Chapter 1460, Statutes of 1989 FY. 2012/2013 Amended $5,913
Administrative License Suspension
Chapter 465, Statutes of 1976 FY. 2012/2013 Late Actual
Peace Officers Procedural Bill of Rights
Chapter 630, Statutes of 1978 FY. 2012/2013 Late Actual
Peace Officer's Personnel Records
Chapter 999, Statutes of 1991 FY. 2012/2013 Late Actual
Rape Victim Counseling Center Notices
Chapter 956, Statutes of 2000 FY. 201212013 Amended $18,3`4O
Identity Theft
Chapter 1120, Statutes of 1996 FY. 2012/2013 Late Actual
Health Benefits for Survivors of Police & Fire
Chapter 901, Statutes of 2000 FY. 2012/2013 Latee Actual
Local Government Employee Relations
FE�i12015 � s1ccLtaG��,`P�P
Received By: ,
y
State Controller's Office
Division of Accounting & Reporting
Local Reimbursement Bureau
State Controller's Office
For State Controller Use Only PROGRAM
DOMESTIC VIOLENCE ARREST POLICIES AND STANDARDS (19) Program Number 00167
CLAIM FOR PAYMENT (20) Date Filed
(21) LRS Input
9843231 Reimbursement Claim Data
CITY FINANCE OFFICER
(
CITY OF CUPERTINO (22) FORM 1,,(04)(a) 81
C 10300 TORRE AVENUE (23) FORM 1, (04)(b) 156
CUPERTINO, CA 95014 1(24) FORM 1, (06)
C (25) FORM 1, (07) A. (g)
Type of Claim
(26) FORM 1, (07) B. (g)
(03) -
(09) Reimbursement ®
(27) FORM 1, (07) C. (g)
(28) FORM 1, (09)
10
(04).
(10) Combined ❑
(29) FORM 1, (10)
606
(05):
(11) Amended ❑
Fiscal Year of Cost
(06)
(12) 2013/2014
(30) FORM 1, (12)
Total Claimed Amount
(07) -.
(13) $6,664
(31) FORM 1, (13)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
(33)
Net Claimed Amount
(16) $6,664
(34)
Due from State
(08)
(17) $6,664
(35)
Due to State
(18)
(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 Government Code.
I further certify that there was no application other than from the claimant, nor any grants or payments 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
+1r
Date Signed 7
/J �1 �
f Telephone Number
X .,
lj i i/, (mss L! i.V.r l,�_ Email Address
Type or Print Name and Title of Authorized`Signatory ^ �L�
(38) Name of Agency Contact Person for Claim
Telephone Number
Email Address
Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883
DAVID WELLHOUSE & ASSOCIATES (DWA) Email Address dwa—renee@surewest.net
Local Mandated Cost Manual
Form FAIVI-27 (Revised 07/14)
State Controller's Office
.ualuuatcu
v.UDL rlanual
PROGRAM
DOMESTIC VIOLENCE ARREST POLICIES AND STANDARDS
FORM
167
CLAIM SUMMARY
I
(01) Claimant
(02) Fiscal Year
CITY OF CUPERTINO
2013/2014
(03) Department
(04) Claim Statistics
(a) Number of reported responses to incidents in the fiscal year of claim
81
(b) Average productive hourly rate including applicable indirect costs (Refer to claiming instructions)
$155.82
(c) Standard time allowed- 29 minutes (0.48 of an hour)
0.48
Unit Cost Method -Reimbursable Activity D
(05) Ongoing Activity
D. Implementation of New Policies [line (04) (a) x (04)(b) x (04)(c)]
6 058
(06 Total Direct and Indirect Costs for Activity D [Carry forward from line (05)(D)]
$6,058
Direct Costs
Object Accounts
Actual Cost Method
(07) One -Time Activities
(a)
Salaries
(b)
Benefits
Materials
and
Supplies
(d)
Contract
Services
(e)
Fixed
Assets
(fl
Travel
and Training
(g)
Total
A. Development of Written Policies
B. Adoption of Written Policies
C. Training Officers on New Policies
(08) Total Direct Costs (A,B,C)
Indirect Costs
(09) Indirec Cost Rate [From ICRP or 10%]
10.00%
(10) Total Indirect Costs [Refer to Claim Summary Instructions]
$606
( I I ) Total Direct and Indirect Costs [Line (06) + line (08)(g) +line (10)]
$6,664
Cost Reduction
(12) Less: Offsetting Revenues
(13) Less: Other Reimbursements
(14) Total Claimed Amount [Line (II) -{line (12) + line (13))]
$6,664
t nral Mandated Cost Manual
uaa« wvnL. .w. -.
For State Controller Use Only PROGRAM
DOMESTIC VIOLENCE ARREST AND VICTIM ASSISTANCE (19) Program Number 00274
CLAIM FOR PAYMENT (20) Date Filed
(21) LRS Input
984323 I Reimbursement Claim Data
CITY FINANCE OFFICER
(22) FORM 1, (04) A. 1. (t)
CITY OF CUPERTINO
10300 TORRE AVENUE (23) FORM 1, (04) A. Z. (r1
st CUPERTINO, CA 95014 (24) FORM 1, (04) A. 3. (f)
c; (25) FORM 1, (04) B. 1. (f) 2,524
Type of Claim
(26) FORM 1, (06)
1O
(27) FORM 1, (07)
959
(03)
(09) Reimbursement ®
(28) FORM 1, (09)
(04)
(10) Combined ❑
(29) FORM 1, (10)
(65)•
(11) Amended ❑
Fiscal Year of Cost
(06)
(12) 2013/2014
(30)
Total Claimed Amount
(07).:
(13) $2,777
(31)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
(33)
Net Claimed Amount
(16) $2777
(34)
Due from State
(08)
(17) $2,777
(35)
Due to State
(18)
(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 i Government Code.
I further certify that there was no application other than from the claimant, nor any grants or payments 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
rl
Date Signed 1 (
^� (� t
_
_ , ("f t� ( �
Telephone Number 1 �
'' i %/lam It 1� Jr� 1-_�
1 i` L i) Email Address L
Type or Print Name and Title of Authorized Signatory
(38) Name of Agency Contact Person for Claim Telephone Number
Email Address
Name of Consulting Firm / Claim Preparer Telephone Number (916) 797-4883
DAVID WELLHOUSE & ASSOCIATES (DWA) Email Address dwa—genes@sureWrest . net:
Form FAM-27 (Revised 07114)
(03) Department
Direct Costs
(04) Reimbursable Components
One -Time Activities
I. Printing Victims Cards
2. Adding Two New Crimes to Response Policy
3. Adding Information to Response Policy
B. Ongoing Activity
Indirect Costs
(06) Indirect Cost Rate
Total Indirect Costs
1(08) Total Direct and Indirect Costs:
Cost Reduction
(09) Less: Offsetting Savings
(10) Less: Other Reimbursements
(II) Total Claimed Amount
Object Accounts
(a) (b) (c) (d) (e) (f)
Salaries Benefits Materials Contract Fixed Total
and Services Assets
( From ICRP )
- (Line (09) + Line ( I
2,%
r........uo.'� nm.
Mandated Cost Manual
MANDATED COSTS
FORM
DOMESTIC VIOLENCE ARRESTS AND VICTIMS ASSISTANCE
2
ACTIVITY COST DETAIL
(01) Claimant (02) Fiscal Year 20 13/20 14
CITY OF CUPERTINO
(03) Reimbursable Components: Check only one box per form to identify the component being claimed.
One -Time Activities
Ongoing Activity
Printing Victim Cards
jj Providing Victims Cards
Adding Two New Crimes to Response Policy
aAdding Information to Response Policy
(04) Description of Expenses
Oblect Accounts
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Employee Names, Job Classifications ,
Hourly
Benefit
Hours
Materials
Contract
Fixed
Total
Functions Performed and Description
Rate or
%
Worked or
Salaries
Benefits
and
Services
Assets
Sal. & Ben.
of Expenses
Unit Cost
Rate
QuantitySupplies
Police Officer
$155.82
16.2
$2,524.28
$2,524
Time spent providing victims cards to victims,
explaing what the card is and how the victim can
use the card, addressing all question about the card
and shelters and providing an Interpreter, if necessary.
Police Officers spent 15 minutes per case.
There were 81 cases during the fiscal year.
OS Total Subtotal
Page: of
$2524
52.524
C)
State Controller's Office
For State Controller Use Only PROGRAM
ADMINISTRATIVE LICENSE SUSPENSION
(19) Program Number 00246
CLAIM FOR PAYMENT
(20) Date Filed 2
246
(21) LRS Input
I 9843231
Reimbursement Claim Data
CITY FINANCE OFFICER
CITY OF CUPERTINO
10300 TORRE AVENUE
(22) FORM 1, (04) A. 1. (h)
(23) FORM 1, (04) A. 2. (h)
344
(24) FORM 1, (04) a. 1. (h)
661_
CUPERTINO, CA 95014
(25) FORM 1, (06)
Type of Claim
(26) FORM 1, (07)
7,005
(03) ,
(09) Reimbursement ®
(27) FORM 1, (09)
10
(28) FORM 1, (10)
700
(04)
(10) Combined ❑
(29)
(D5)
(11) Amended ❑
Fiscal Year of Cost
(06)
(12) 2013/2014
(30)
Total Claimed Amount
(07)
(13) 05
(31)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
(33)
Net Claimed Amount
(16) 7 705
(34)
Due from State
(08)
(17) $7,705
(35)
Due to State
(18)
(36)
(37) CERTIFICATION OF CLAIM
In accordance with the provisions of Government Code Sections 17560 and 17561,! 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 I Government Code.
I further certify that there was no application other than from the claimant, nor any grants or payments 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 1 �� �/�1�t��y J
Telephone Number 7/,; ! l `
IrvCt't(,L ClK C j-yLEmailAddress (_i 1 (1 4v (_Lt.
Type or Print Name and Title of Authorized Signatory
(38) Name of Agency Contact Person for Claim Telephone Number
Email Address
Name of Consulting Firm/Claim Preparer (916) 797-4883
Telephone Number
DAVID WELLHOUSE & ASSOCIATES (DWA) Email Address diva-renee@surevres net
Local Mandated Cost Manual
Form FAM-27 (Revised 07/14)
State Controller's Office
wca1 ro%dnuaceu
t,.ost ivianual
For State Controller Use Only
PROGRAM
PEACE OFFICERS PROCEDURAL BILL OF RIGHTS (POBOR)
(19)
CLAIM FOR PAYMENT
Program Number 00187
(20) Date Filed
(21) LRS Input
9843231
Reimbursement Claim Data
CITY FINANCE OFFICER
RM 1, (04)
T(233)
30
CITY OF CUPERTINO
RM 1, (05)
1,309
10300 TORRE AVENUE
(24) FORM 1, (06)(A)(g)
CUPERTINO, CA 95014
(25) FORM 1, (06)(B)(g)
Type of Claim
(26) FORM 1, (06)(C)(g)
(03)
(09) Reimbursement ®
(27) FORM 1, (06)(D)(g)
(04)
(10) Combined ❑
(28) FORM 1, (08)
.(05)
(11)Amended ❑
(29) FORM 1, (09)
Fiscal Year of Cost
(06) .
(12) 2013/2014
(30) FORM 1, (11)
Total Claimed Amount
(07)
(13)
(31) FORM 1, (12)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
(33)
Net Claimed Amount
(16) $1,309
(34)
Due from State
(08)
(17) $1,309
(35)
Due to State
(18)
(36)
(37) CERTIFICATION OF CLAIM
In accordance with the provisions of Government Code Sections 17560 and 17561, 1 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 I Government Code.
I further certify that there was no application other than from the claimant, nor any grants or payments 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
`Th
Telephone Number l(L 2L7
>/ ' 1 1L C L (A -�� ,7 i Email Address L 1
Type or Print Name and Title of AuthorizelSignatory
(38) Name of Agency Contact Person for Claim
Telephone Number
Email Address
Name of Consulting Firm/Claim Preparer
Telephone Number (916) 797-4883
DAVID WFTLBOUSE & ASSOCIATES (DWA) Email Address dwa—renee@surewest.net
orm FAM-27 (Revised 0(/14)
PROGRAM
187
PEACE OFFICERS PROCEDURAL BILL OF RIGHTS (POBOR)
CLAIM SUMMARY
FORM
1
(01) Claimant
CITY OF CUPERTINO
(02) Fiscal Year
20132014
(03) Department
Claim Statistics
(04) Number of full-time sworn peace officers employed by the agency during this fiscal year
30
Flat Rate Method
(05) Total Cost [Line (04) X $43.64 for 2013-14 FY] [Skip (06) to (09) and carry forward total to line (10)]
$1,309
Actual Cost Method
Direct Costs
Object Accounts
(06) Reimbursable Activities
(a)
Salaries
(b)
Benefits
(c)
Materials
And
Supplies
(d)
Contract
Services
(e)
Fixed
Assets
(f)
Travel
And
Training
(g)
Total
A. Administrative Activities
B. Administrative Appeal
C. Interrogations
D. Adverse Comment
(07) Total Direct Costs
Indirect Costs
(08) Indirect Cost Rate
[From ICRP or 10%]
(09) Total Indirect Costs
[Refer to Claim Summary Instructions]
(10) Total Direct and Indirect Costs
[Refer to Claim Summary Instructions]
Cost Reduction
(11) Less: Offsetting Revenues
(12) Less: Other Reimbursements
(13) Total Claimed Amount
[Line (10) - {line (11) + line (12))]
Revised 07/14
State Controller's Office
For State Controller Use Only
PROGRAM
CALIFORNIA PUBLIC RECORDS ACT
CLAIM FOR PAYMENT
(19) Program Number 00353
(20) Date Filed
(21) LRS Input
( 984323 I
Reimbursement Claim Data
CITY FINANCE OFFICER
(
CITY OF CUPERTINO
(22) Form 1, (04) A. 1. (g)
(23) Form;1, (04) A. 2. (g)
C 10300 TORRE AVENUE
(24) Form 1, (04) B. 1. a. (g)
9,951
CUPERTINO, CA 95014
(25) Form 1, (04) B. 1. b. (g)
c
Type of Claim
(26) Form 1, (04) B. 2. a. (g)
437
(03)
(09) Reimbursement ®
(27) Form 1, (04) B. 2. b. (g)
(28) Form 1, (04) B. 2.o. (g)
(04)
(10) Combined ❑
(29) Form 1, (04) B. 3. a. (g)
(05)
(11) Amended ❑
Fiscal Year of Cost
(06)
(12) 2013/2014
(30) Form 1, (04) B. 3. b. (g)
Total Claimed Amount
,(07)
(13) $11,427
(31) Form 1, (04) B. 3. c. (g)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32) Form 1, (06)
10
Less: Prior Claim Payment Received
(15)
(33) Form 1, (07)
1,039
Net Claimed Amount
(16) $11,427
(34) Form 1, (09)
Due from State
(08) -
(17) $11,427
(35) Form 1, (10)
Due to State
(18)
(36)
(38) 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 I Government Code.
I further certify that there was no application other than from the claimant, nor any grants or payments 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
� a
��,,��77 (/l, ] Date SignedX ( + 3—
Lt f t Telephone Number 1� %S / /
((,l C ) I �1 1 r 1, ( (,, G_rJ/�)u%ir),.�,�.
(; Urb�. ; � .� C�,r IL. Email Address if r f SL'J, ;�
Type or Print Name and Title of Authorized Signatory
(39) Name of Agency Contact Person for Claim Telephone Number
Email Address
Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883
DAVID WELLHOUSE & ASSOCIATES (DWA) Email Address dwa—renee@surewest:.net;
Local Mandated Cost Manual
Form FAM-27 (Revised 07/14)
State Controller's Office
Local Mandated Cost Manual
PROGRAM CALIFORNIA PUBLIC RECORDS ACT
FORM
353 CLAIM SUMMARY
I
(01) Claimant:
(02) Fiscal Year: 2013/2014
CITY OF CUPERTINO
(03) Department
Direct Costs Object Accounts
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(04) Reimbursable Activities
Salaries
Benefits
Materials
Contract
Fixed
Travel
Total
and
Services
Assets
and
Supplies
Training
A. One Time Activities
to Implement the Mandate
1. Developing Policies, Protocols,
Manuals and Procedures
$0
$0
$0
2. Training Employees
$0
$0
$0
B. Ongoing Activities
1.a Computer programming, extraction,
or compiling to produce disclosable
$8,862
$1,089
$9,951
records
1.b Producing a copy of an electronic
record
$0
$0
$0
2.a Provide verbal or written notice
within 10 days from receipt of a request
$301
$136
$437
(Reimbursement begin 01/01/2002)
2.b Provide written notice if extension
beyond the 10 days is granted
$0
$0
$0
(Reimbursement begins 01/01/2002)
2.c Provide written notice if extension is
denied.
$0
$0
$0
3.a Confer with the requestor if
clarification is needed to identify
$0
$0
$0
records requested
3.b Identify records and information
which may be disclosable
$0
$0
$0
3.c Provide suggestions for overcoming
any basis for denying access to the
$0
$0
$0
records
(05) Total Direct Costs
$9,163
$1,226
$10,389
Indirect Costs
(06) Indirect Cost Rate [From ICRP or 10%]
10.00%
(07) Total Indirect Costs [Refer to Claim Summary Instructions]
$1,039
(08) Total Direct and Indirect Costs [Line (05)(g)+line(07)
$11,427
Cost Reduction
(09) Less: Offsetting Revenues
(10) Less: Other Reimbursements
(11) Total Claimed Amount [Line (08) -{line (09) +line (10))]
$11,427
INew 10/13
State Controller's Office
Local Mandated Cost Manual
PROGRAM
CALIFORNIA PUBLIC RECORDS ACT
FORM
353
ACTIVTY COST DETAIL
2
(01) Claimant
(02) Fiscal Year
CITY OF CUPERTINO
2013/2014
A. One Time Activities to Implement the Mandate
❑ 1. Developing Policies, Protocols, Manuals and ❑ 2. Training Employees
Procedures
B. Ongoing Activities
O 1.a Computer Programming, extraction, or compiling to ❑ 2.c Provide written notice is extension is denied
produce disclosable records
❑ 1.b Producing a copy of an electric record ❑ 3.a Confer with the requester if clarification is needed
to identify records requested
❑ 2.a Provide verbal or written notice within 10 days from ❑ 3.b Identify records and information which may be
receipt of a request (Reimbursement begins disclosable
01/01/2002)
❑ 2.b Provide written notice if extension beyond the 10 ❑ 3.c Provide suggestions for overcoming any basis for
days is granted (Reimbursement begins denying access to the records
1/1/2002)
(04) Description of Expenses
Object Accounts
(a)
(b)
(c)
(d)
(e)
(g)
(e)
(i)
Employee Names, Job
Hourly
Hours
Salaries
Benefits
Contract
Fixed
Travel
Classifications, Functions Performed
Rate or
Worked or
Services
Assets
and
and Descriptions of Expenses
Unit Cost
Quantity
Training
City Clerk
$60.15
52
$3,128
$246
Director Admin Svcs
$95.77
23
$2,203
$435
Admin Secretary
$38.11
23
$877
$129
Deputy City Clerk
$39.46
5
$197
$72
Associate Planner
$50.55
25
$1,264
$87
Building Official
$70.23
17
$1,194
$121
(05) Total Subtotal Page of
$8,862
$1,089
U
State Confi•nll�lr'R nffira
L OCai rvisnca•fej
For State Controller Use Only
Goof Manual
PROGRAM
ADMINISTRATIVE LICENSE SUSPENSION
CLAIM FOR PAYMENT
(19) Proyrart Number 00240^
120; Date Fi!ad
�
r G
(21) LRS Input
9843231
CITY FINANCE OFFICER
Reimbursement Claim
Data
CITY OF CUPERTINO
(22) FORM 1, )04) A. 1. (h)
10300 TORRE AVENUE
"-"`"-'--"'�"'-"-' `�•
(23) FORM 1, (04) A. 2. (h)
-r-`-'�--__._.
CUPERTINO, CA 95014
(24) FOP,>41. (04)S. 1. (h)
5,376
(25) FORM 1. (06)
Type of Claim
(26) FORM 1. (07)
5,376
(03)
(09) Reimbursement Q
�___
(27) FORM 1. (09) - 10
(04)
(10) Combined L._.!
+(28) FORM 1, (10) 538
(05)
(11) Amended
(29)
Fiscal Year of Cost
(06)
(12) 2012/2013
(30)
()-__._-_.____ -----_ _ _, _..•._
Totai Claimed Amount
(07)
(13) $5,913
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
.---�_—_-f34i
(33)
NotCiaimadAmount
(16)
- -------___-------------.- _---
Due from State (08)
(17) $5,913
(35)
Due to State
(16).
(36)
(37) CERTIFICATION OF CLAIM
In accordance with the provisions of Government Code Sections 17660 and 17561, 1 certify that I am the officer authorizoci 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 I Government Code.
I further certify that there was no application other than from the claimant, nor any grants or payments 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 sit 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
— P.iG'v Telephone Number
a )
ZLl E -Mail Address
Type or Pant IV2mc 2nd Tit12 of Authorized 3iynat��ry
V-�' ���� �w
(38) Name of Agency Contact Person for Claim Telephone Number .
----•-- --. E -!nail Address
— .-------•--_-_------------
Name of Consulting Firm.' Claim Preparer
Telephone rtn:i:er f 916'1 797-4883
DAVID 14ELLHOUS13 & ASSOCIATES E-mail Address r1cT�?—rrarrc�r.•(darvr t� c{• ,�:,t.
(I1,sv Icwu VIII 3J1
Claim Statistics
(03) Leave Blank
Direct Costs
(04) Reimbursable Activities
A. Minors Detained But Not Arrested
I. Admonishing Drivers/Screening Tests on
Minor (IV.A. I & 2)
2. Seizing Licenses & Serving Notices/
Completing Sworn Reports/Submitting
Reports to DMV (IV.A.3. to AS.)
B. Arrested Drivers for Violation of DUI Statute
I. Seizing Licenses & Serving Notices/
Completing Sworn Reports/Submitting
Reports to DMV (IV.B.I. to B.3.)
C. Arrested Drivers for Controlled Substances
Reimbursable for FY's 1997.98 to 1998-99 only
I. Informing Arrested Drivers of
FORM
ALS- I
Fiscal
Year
2012/2013
Object Accounts
(a)
b
c
d
(e)
(h)
Number
Uniform
Salary
Benefit
Subtotal
Subtotal
Materials
Total
of
Time
Hourly
Rate
Salaries
Benefit
and
Cases
Allowance
Rate
(a) x (b) x (c)
(d) x (e)
Supplies
(e) + (f) + (g)
2.74
Li 0.25 $155.82 L $S,3760 0 0 $5.376
0.0083
(05) Total Direct Costs
t
�:;;:;;:.;<.:.<':<:'.i;:;S`:<si:::;<`:.:;≤;',;i:is'::<;"i':::�:`'::;:;;;;�;: ��
5 376
$ ��JL
J
$5,376
Indirect Costs
(06) Indirect Cost Rate
{ From ICRP
Fixed Rate
10.00%
(07) Total Indirect Costs
Line (06) x line (05)(e)]
$538
(08) Total Direct and Indirect Costs:
[{Line (OS)(h) +line 07 ]
$5,9 13
Cost Reduction
(09) Less; Offsetting Savings
(10) Less; Other Reimbursements
(II) Total Claimed Amount
[Line (08) - {line (09) + line (I 0)}]
$ 5 9 13
Q6..6.. /x....6...11...) A#P..e
Local Mandated Cost Manual
vww v
For State Controller Use Only
PROGRAM
(19) Program Number00321
(20) Date Filed
IDENTITY THEFT
CLAIM FOR PAYMENT
(21) LRS Input
( 984323 I
Reimbursement Claim Data
( CITY FINANCE OFFICER
CITY OF CUPERTINO
10300 TORRE AVENUE
(22) FORM 1,(04) 1. (a) (9)
8,336
(23) FORM 1, (04) 1. (b) (g)
CUPERTINO, CA 95014
(24) FORM 1, (04) 2. (g)
8 .336
(25) FORM 1, (06)
10
Type of Claim
(26) FORM 1, (07)
1.6.67
(27) FORM 1, (09)
(03)
(09) Reimbursement ❑
(28) FORM 1, (10)
(04)
(10) Combined ❑
(29)
(05)
(11) Amended ®
Fiscal Year of Cost
(0.
(12)2012/2013
(30)
Total Claimed Amount
(07)
(13) $,1,4Q
(31)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
(33)
Net Claimed Amount
(16) • $18,340
(34)
Due from State
(08)
(17) $18 340
(35)
Due to State
(18)
(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 I Government Code.
I further certify that there was no application other than from the claimant, nor any grants or payments 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 G�IL j Telephone Number /7'08 7 % 3 22- Y
I. t ( f( E -Mall Address
Type or Print Name and Title of Authorized Signatory
(38) Name of Agency Contact Person for Claim Telephone Number
E-mail Address
Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883
DAVID WELLHOUSE & ASSOCIATES E-mail Address rn—rPnee@surewest.uet
Form FAM-27 (Revised 07/13)
(03) Department
Direct Costs I Object Accounts
(04) Reimbursable Components (a) (b) (c) (d) (e) (f)
Salaries Benefits Materials Contract Fixed Total
and Services Assets
I. Choose either a) or b)
a) Taking police report in violation of PC 530.0
b) Reviewing online ID theft report
Investigation of facts II $8.336
Indirect Costs
(06) Indirect Cost Rate (From ICRP
Salaries & B
(07) Total Indirect Costs
Total Direct and Indirect Costs:
Cost Reduction
(09) Less: Offsetting Savings
(10) Less: Other Reimbursements
(II) Total Claimed Amount
Line (08)- {Line (09) + Line I0 18 340
wised 01/07
St+i•e Gnotrnlier's f]mrn
r,s
IDENTITY THEFT
FORM
2
ACTIVITY COST DETAIL
(01) Claimant
(02) Fiscal Year 20 I 220 I 3
CITYOF CUPERTINO
(03) Reimbursable Activities Check only one box per form to identify the activity being claimed.
Taking police report in violation of PC § 530.5
Investigation of facts
❑ Reviewing online ID theft report
(041 Description of Expenses
Ob ect Accounts
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Employee Names, Job Classifications,
Hourly
Benefit
Hours
Materials
Contract
Fixed
Total
Functions Performed and Description
Rate or
%
Worked or
Salaries
Benefits
and
Services
Assets
Sal. & Ben.
of Expenses
Unit Cost
Rate
QuantitySupplies
Police Officer
$155.82
53.5
$8,336.37
$8,336
Taking a police report in violation of Penal Code
Section 530.5 which includes time to draft, review,
and edit the identity theft report.
The Police Department took 107 reports during the
fiscal year.
Hourly rate includes salary and benefits.
OS Total Subtotal
Page: of
$8,336
$8,336
New 0911 1
IDENTITY THEFT
FORM
2
ACTIVITY COST DETAIL
(01) Claimant
(02) Fiscal Year 201 2/20 13
CITYOF CUPERTINO
(03) Reimbursable Activities Check only one box per form to Identify the activity being claimed.
Taking police report in violation of PC §530.5
® Investigation of facts
Reviewing online ID theft report
04 Description of Expenses
Object Accounts
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Employee Names, Job Classifications ,
Hourly
Benefit
Hours
Materials
Contract
Fixed
Total
Functions Performed and Description
Rate or
%
Worked or
Salaries
Benefits
and
Services
Assets
Sal. & Ben.
of Expenses
Unit Cost
Rate
QuantitySupplies
Police Detective $155.82
53.5
$8,336.37
$8,336
Begin an Investigation of the facts, including gathering
facts sufficient to determine where the crime(s)
occurred and what peices of personal
identifying information were used for an
unlawful purpose
Hourly rate Includes salary and benefits.
OS Total Subtotal Page, of
11 $8,336
II 336
New 09111