HomeMy WebLinkAbout17-167 David Wellhouse & Associates, Inc._Claim Reimbursement sheets for FY 2016-2017avid Wellhouse
...and Associates, Inc.
February 28, 2018
Ms. Grace Schmidt
City Clerk
City of Cupertino
10300 Torre Avenue
Cupertino, California 95014
RE: COPIES OF FEBRUARY 2018 STATE MANDATED COST REIMBURSEMENT CLAIMS
Dear Ms. Schmidt:
Enclosed are the copies of the February 2018 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 2018 state mandated cost reimbursement claims. Should you have any questions, please contact
me at (916) 797-4883.
Sincerely,
Renee M. Wellhouse
Enclosures
3609 Bradshaw Road, Suite H-382 • Sacramento, California 95827
(916) 797-4883 • FAX (916) 797-4887
• David Wellhouse
...and Associates, Inc.
STATE MANDATED COST CLAIMS RECEIPT
FEBRUARY 2018 STATE MANDATED COST CLAIMS
AGENCY: CITY OF CUPERTINO
DATE: FEBRUARY 15, 2018
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
Chapter 256, Statutes of 1995 FY. 2016/2017
Domestic Violence Arrest Standards
Chapter 698 & 702, Statutes of 1998 FY. 2016/2017
Domestic Violence Arrest & Victim Assistance
Chapter 1460, Statutes of 1989 FY. 2016/2017
Administrative License Suspension
Chapter 465, Statutes of 1976 FY. 2016/2017
Peace Officers Procedural Bill of Rights
Chapter 630, Statutes of 1978 FY. 2016/2017
Peace Officer's Personnel Records
Chapter 999, Statutes of 1991 FY. 2016/2017
Rape Victim Counseling Center Notices
Chapter 901, Statutes of 2000 FY. 2016/2017
Local Government Employee Relations
Chapter 1120, Statutes of 1996 FY. 2016/2017
Health Benefits for Survivors of Police & Fire
Received By:
State Controller's Office
Division of Accounting & Reporting
Local Reimbursement Bureau
AMOUNT
$3,714
$8,907
$2,528
$17,092
$8,907
�I
State Controller's Office
For State Controller Use Only
PROGRAM
(19) Program Number 00167
DOMESTIC VIOLENCE ARREST POLICIES AND STANDARDS
CLAIM FOR PAYMENT
(20) Date Filed
(21) LRS Input
(C 984323 I
Reimbursement Claim Data
CITY FINANCE OFFICER
CITY OF CUPERTINO
(22) FORM 1, (04)(a)
(23) FORM 1, (04)(b)
C 10300 TORRE AVENUE
5 CUPERTINO, CA 95014
(24) FORM 1, (06)
(25) FORM 1, (07)A. (g)
3,376
_
Type of Claim
(26) FORM 1, (07) B. (g)
10
(27) FORM 1, (07) C. (g)
338
(03)
(09) Reimbursement ®
(28) FORM 1, (09)
(04)
(10) Combined ❑
(29) FORM 1, (10)
(05)
(11) Amended ❑
Fiscal Year of Cost
(06)
(12) 2016/2017
(30) FORM 1,(12)
Total Claimed Amount
(07)
(13) $3714
(31) FORM 1, (13)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received 1(15)
(33)
Net Claimed Amount
(16) $3,714
(34)
Due from State
(08)
(17)
(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 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
J Date Signed
Telephone Number 'i✓C'J �,__• _ -� _�
i' lA4 ( y (.J/L Email Address (. k'i:1
Type or Print Name and Title of Authorized Signat .ry ! I j
(38) Name of Agency Contact Person for Claim Telephone Number
Email Address
Name of Consulting Firm I Claim Preparer Telephone Number (916) 707_4883
DAVID WELLHOUSE & ASSOCIATES (DWA) Email Address dwa—renee@suretestnet=
Local Mandated Cost Manual
Form FAM-27 (Revised 10/17)
(01) Claimant II (02) Type of Claim Fiscal Year
CITY OF CUPERTINO
2016/2017
(03) Department
Direct Costs Object Accounts
(04) Reimbursable Components (a) (b) (c) (d) (e) (f)
Salaries Benefits Materials Contract Fixed Total
and Services Assets
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 (From ICRP )
Total Indirect Costs
1(08) Total Direct and Indirect Costs:
+ line roan II $3.714 I
Cost Reduction
(09) Less: Offsetting Savings
(10) Less: Other Reimbursements
(II) Total Claimed Amount
State Controller's Office
MANDATED COSTS
FORM
DOMESTIC VIOLENCE ARRESTS AND VICTIMS ASSISTANCE
2
ACTIVITY COST DETAIL
(01) Claimant
(02) Fiscal Year 20 I 6/20 I 7
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
Providing Victims Cards
Adding Two New Crimes to Response Policy
Adding Information to Response Policy
(04) Description of Expenses
Object Accounts
(a)
(b)
(c)
(d)
��
(f) (g)
(h)
—
Employee Names, Job Classifications,
Hourly
Benefit
Hours
Materials Contract
Fixed
Total
Functions Performed and Description
Rate or
°b
Worked or
Salaries
Benefits
and Services
Assets
Sal. & Ben.
of Expanses
Unit Cost
Rate
QuantitySupplies
Police Officer
$155.82
21.7
$3,376.10
$3,376
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 20 minutes per case.
There were 65 cases during the fiscal year.
OS Total Subtotal
Page: of
$3,376
$3,376
ci
State Controller's Office
For State Controller Use Only
PROGRAM
(19) Program Number 00274
DOMESTIC VIOLENCE ARRESTS AND VICTIM ASSISTANCE
CLAIM FOR PAYMENT
(20) Date Filed
(21) LRS Input
984323 I
Reimbursement Claim Data
( CITY FINANCE OFFICER
CITY OF CUPERTINO
(22) FORM 1, (04)A. 1. (f)
(23) FORM 1, (04) A. 2. (f)
10300 TORRE AVENUE
CUPERTINO, CA 95014
(24) FORM 1, (04) A. 3. (f)
8,907
(25) FORM 1, (04) B. 1. (f)
c
Type of Claim
(26) FORM 1, (06)
(03)
(09) Reimbursement ®
(27) FORM 1, (07)
10
(04)
(10) Combined
(28) FORM 1, (09)
810
(29) FORM 1, (10)
(05)
(11) Amended
Fiscal Year of Cost
(06)
(12) 201612017
(30)
Total Claimed Amount
(07)
(13) $8,907
(31)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
(33)
Net Claimed Amount
(16) $8,907
(34)
Due from State
(08)
(17)
(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 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 correc₹.
Signature of Authorized Officer
n I ! Date Signed ( j ( ( �ff
Telephone Number (( rf ` i� /` 1 c
c4 (1�ti`.yi Email Address 1 I t l
Type or Print Name and Title of Authorized sig� ( J
(38) Name of Agency Contact Person for Claim Telephone Number
Email Address
Name of Consulting Firm I Claim Preparer Telephone Number (91 6) 797-488.3.._...
DAVID WELLHOUSE & ASSOCIATES (DWA) Email Address dwa—renee@surewest,net
I nrnl Msnr1 teri Cncf Manual
Form FAM-27 (Revised 10117)
PROGRAM
264
PEACE OFFICER PERSONNEL RECORDS:
UNFOUNDED COMPLAINTS AND DISCOVERY
CLAIM SUMMARY
FORM
1
(01) Claimant
CITY OF CUPERTINO
(02)
Fiscal Year
2016/2017
(03) Department
Direct Costs
Object Accounts
(04) Reimbursable Activities
(a) Salaries
(b)
Benefits
(c)
Materials
and
Supplies
(d)
Contract
Services
(e)
Fixed
Assets
(f)
Total
A. Notice to Peace Officers
1. Provide Immediate Notice to Officer
B. Record Retention
1. Retain Complaints and Reports for 3 More
Years
2. Maintain Separate Files
$8,097
$8,097
C. Notice to Complaining Parties
1. Provide a Copy of Complaint to
Complainant
2, Provide Written Notification to Complainant in 30 days
$0
(05) Total Direct Costs
Indirect Costs
$8,097
$8,097
(06) Indirect Cost Rate
[From ICRP or 10%]
10.00%
(07) Total Indirect Costs
[Refer to Claim Summary Instructions]
$810
(08) Total Direct and Indirect Costs
[Line (05)(f) + line (07)]
$8,907
Cost Reduction
(09) Less: Offsetting Revenues
(10) Less: Other Reimbursements
(11) Total Claimed Amount
[Line (08) - {line (09) + line (10))]
$8,907
PROGRAM PEACE OFFICER PERSONNEL RECORDS: FORM
2 �� UNFOUNDED COMPLAINTS AND DISCOVERY
ACTIVITY COST DETAIL 2
(01) Claimant (02) Fiscal Year
CITY OF CUPERTINO 2016/2017
(03) Reimbursable Activities: Check only one box per form to identify the activity being claimed.
A. Notice to Peace Officers B. Record Retention C. Notice to Complaining Party
❑ 1. Provide Immediate ❑ 1. Retain Complaints and 1. Provide a Copy of
Notice to Officer Reports for 3 More Complaints to
Years Complainant
i] 2. Maintain Separate Files ❑ 2. Provide Written
Notification
(04) Description of Expenses
(a)
Employee Names, Job Classifications,
Functions Performed,
and Description of Expenses
Lieutenant
Sergeant
Time spent for receipt of notice that discovery
or disclosure is sought of peace officer
personnel records and notificaiton of the
individual whose records are sought.
Total Subtotal Pa
(b)
(c)
Hourly
Hours
Rate or
Worked or
Unit Cost
Quantity
$186.44
10
$155.82
40
of
Object Accounts
(d) (e)
Salaries Benefits
$1,864.40
$6,232.80
$8,097
(f) (g) (h)
Materials Contracted Fixed
and Services Assets
Supplies
PROGRAM
PEACE OFFICER PERSONNEL RECORDS:
FORM
264
UNFOUNDED COMPLAINTS AND DISCOVERY
ACTIVITY COST DETAIL
2
(01) Claimant
(02) Fiscal Year
CITY OF CUPERTINO
2016/2017
(03) Reimbursable Activities: Check only one box per form to identify the activity being claimed.
A. Notice to Peace Officers B. Record Retention C. Notice to Complaining Party
❑ 1. Provide Immediate D 1. Retain Complaints and ❑ 1. Provide a Copy of
Notice to Officer Reports for 3 More Complaints to
Years Complainant
E 2. Maintain Separate Files ❑ 2. Provide Written
Notification
(04) Description of Expenses
Object Accounts
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Employee Names, Job Classifications,
Hourly
Hours
Salaries
Benefits
Materials
Contracted
Fixed
Functions Performed,
Rate or
Worked or
and
Services
Assets
and Description of Expenses
Unit Cost
Quantity
Supplies
Lieutenant
$186.44
10
$1,864.40
$6,232.80
Sergeant
$155.82
40
Time spent for receipt of notice that discovery
or disclosure is sought of peace officer
personnel records and notificaiton of the
individual whose records are sought.
$8,097
(05) Total Subtotal Page: _ of — _
State Controller's Office
For State Controller Use Only
PROGRAM
(19) Program Number 00246
ADMINISTRATIVE LICENSE SUSPENSION - PER SE
CLAIM FOR PAYMENT
(20) Date Filed
(21) LRS Input
984323 I
Reimbursement Claim Data
CITY FINANCE OFFICER
CITY OF CUPERTINO
(22) FORM 1, (04) A. 1. (h)
10300 TORRE AVENUE
(23) FORM 1, (04) A. 2. (h)
CUPERTINO, CA 95014
(24) FORM 1, (04) B. 1. (h)
2,259
(25) FORM 1, (06)
10
Type of Claim
(26) FORM 1, (07)
230
(27) FORM 1, (09)
(03)
(09) Reimbursement ®
(28) FORM 1, (10)
(04)
(10) Combined ❑
(05)
(11) Amended ❑
(29)
Fiscal Year of Cost
(06)
(12) 2016/2017
(30)
Total Claimed Amount
(07)
(13) $2,528
(31)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
(33)
Net Claimed Amount
(16) $2,528
(34)
Due from State
(08)
(17) 2 .528
(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 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 ^7 t / l
Telephone Number
\rt' L/l,,e t'4. t C -(h 1
Type or Print Name and Title of Authorized Signatory'-
C 't'L Email Address t i Si ''
(38) Name of Agency Contact Person for Claim
Telephone Number
Email Address
Name of Consulting Firm / Claim Preparer
TeiepnoneNumber (916) 797-4883
DAVID WELLIOUSE & ASSOCIATES (DWA) Email Address dwaa—renee@surewest..uet
Local Mandated Cost Manual
Form FAM-27 (Revised 10/17)
state Controller's Office
Local Mandated Cost Manual
PROGRAM Administrative License Suspension- Per Se
FORM
246
CLAIM SUMMARY
1
01) Claimant:
(02)
Fiscal Year: 2016/2017
;ITY OF CUPERTINO
03) Department
)irect Costs
Object Accounts
(a)
(b)
(c)
(d) (e)
(f)
(g)
(h)
Number
Uniform
Time
Salary
Hourly
Benefit Subtotal
Subtotal
Benefits
Materials &
Total
04) Reimbursable Activities
of cases
Allowance
Rate
Rate Salaries
(d) x (e)
Supplies
(e) +(f)+(g)
(a) x(b) x(c)
1. Minors Detained But Not Arrested
• Admonishing Drivers/Screening Tests on
Minors (IV.A1. & 2.)
0.2667
'.. Seizing Licenses & Serving
'lotices/Completing Sworn Reports/
submitting Reports to DMV (IV. A. 3. to A.
i.)
1
0.2500
$155.82
$38.96
$38.96
3. Arrested Drivers for Violation of DUI
Statute
I. Seizing Licenses & Serving Notices/
;ompleting Sworn Reports/ Submitting
Reports to DMV (IV. B.1 to B. 3.)
58
0.2500
$155.82
$2,259
$2,259
05) Total Direct Costs
$2,298
$2,298
ndirect Costs
06) Indirect Cost Rate
[From ICRP or 10%]
10,00%
07) Total Indirect Costs
[Line (06) x line (05)(e)]
$230
:08) Total Direct and Indirect Costs
[Line (05)(g)+line(07)
$2,528
ost Reduction
;09) Less: Offsetting Revenues
;10) Less: Other Reimbursements
;11) Total Claimed Amount
[Line (08) -{line (09) +line (10))]
$2,528
State Controller's Office Local Mandated Cost Manual
For State Controller Use Only I PROGRAM
PEACE OFFICERS PROCEDURAL BILL OF RIGHTS
CLAIM FOR PAYMENT
9) Program Number 00187
0) Date Filed 1
87
1) LRS Input
984323 I
CITY FINANCE OFFICER
CITY OF CUPERTINO
10300 TORRE AVENUE
CUPERTINO, CA 95014
Reimbursement
Claim Data
(22) FORM 1, (04)
(23) FORM 1, (05)
(24) FORM 1, (06)(A)(g)
14,915
(25) FORM 1, (06)(B)(g)
623
(03)
(04)
(05)
Type of Claim
(09) Reimbursement ®
(10) Combined ❑
(11) Amended ❑
(26) FORM 1, (06)(C)(g)
(27) FORM 1, (06)(D)(g)
10
(28) FORM 1, (08)
1,554
(29) FORM 1, (09)
Fiscal Year of Cost
(06)
(12) 2016/2017
(30) FORM 1, (11)
Total Claimed Amount
(07)
(13) $17092
(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) $17.092
(34)
Due from State
(08)
(17) $17,092
(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 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
Type or Print Name and Title of Authorized Signatory
(38) Name of Agency Contact Person for Claim
Name of Consulting Firm / Claim Preparer
DAVID WELLHOUSE & ASSOCIATES (DWA)
Form FAM-27 (Revised 10117)
Date Signed , -- ( (I ,f
Telephone Number C' rr` 77 j
I f
Email Address E -id C _LS ✓� `�k ( t.. ,-_ a i 7,:.�,
Telephone Number
Email Address
Telephone Number (916) 797_4RR'�
Email Address dwa®renee@suretwest o net
PROGRAM
187
PEACE OFFICERS PROCEDURAL BILL OF RIGHTS
CLAIM SUMMARY
FORM
1
(01) Claimant
CITY OF CUPERTINO
(2) Fiscal Year
201612017
(03) Department
Claim Statistics
(04) Number of full-time sworn peace officers employed by the agency during this fiscal year
Flat Rate Method
(05) Total Cost [Line (04) X $47.18 for 2016-17 FY] [Skip (06) to (09) and carry forward total to line (10)]
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
$14,915
$14,915
B. Administrative Appeal
C. Interrogations
$623
$623
D. Adverse Comment
(07) Total Direct Costs
$15,538
$15,538
Indirect Costs
(08) Indirect Cost Rate
[From ICRP or 10%]
10.00%
(09) Total Indirect Costs
[Refer to Claim Summary Instructions]
$1,554
(10) Total Direct and Indirect Costs
[Refer to Claim Summary Instructions]
$17,092
Cost Reduction
(11) Less: Offsetting Revenues
(12) Less: Other Reimbursements
(13) Total Claimed Amount
[Line (10) - (line (11) + line (12))]
$17,092
PROGRAM
187
PEACE OFFICERS PROCEDURAL BILL OF RIGHTS
ACTIVITY COST DETAIL
FORM
2
(01) Claimant CITY OF SAN MATEO
(02) Fiscal Year
2016/2017
(03) Reimbursable Activities: Check only one box per form to identify the activity being claimed.
A. Administrative Activities ❑ C. Interrogations
❑ B. Administrative Appeal ❑ D. Adverse Comment
(04) Description of Expenses
Object Accounts
(a)
Employee Names, Job Classifications,
Functions Performed and Description of
Expenses
(b)
Hourly Rate
or Unit Cost
(c)
Hours
Worked or
Quantity
(d)
Salaries
(e)
Benefits
(f)
Materials
And Supplies
(g)
Contract
Services
(h)
Fixed
Assets
(i)
Travel
And
Training
Captain Michael Doty
$186.44
80
$14,915
(05) Total Subtotal Page:_ of
$14,915
PROGRAM
PEACE OFFICERS PROCEDURAL BILL OF RIGHTS
FORM
187
ACTIVITY COST DETAIL
2
(01) Claimant CITY OF SAN MATEO
(02) Fiscal Year
2016/2017
(03) Reimbursable Activities: Check only one box per form to identify the activity being claimed.
❑ A. Administrative Activities j C. Interrogations
❑ B. Administrative Appeal ❑ D. Adverse Comment
(04) Description of Expenses
Object Accounts
(a)
Employee Names, Job Classifications,
(b)
Hourly Rate
(c)
Hours
(d)
Salaries
(e)
Benefits
(f)
Materials
(g)
Contract
(h)
Fixed
(i)
Travel
Functions Performed and Description of
or Unit Cost
Worked or
And Supplies
Services
Assets
And
Expenses
Quantity
Training
Bret Moore -Sergeant
$155.82
4
$623
(05) Total Subtotal Page:_ of
$623
U
State Controller's Office
For State Controller Use Only
PROGRAM
PEACE OFFICER PERSONNEL RECORDS:
UNFOUNDED COMPLAINTS AND DISCOVERY
(19) Program Number 00264
CLAIM FOR PAYMENT
(20) Date Filed
(21) LRS Input
( 984323 I
Reimbursement Claim Data
CITY FINANCE OFFICER
CITY OF CUPERTINO
(22) FORM 1,(04)A.1.(f)
(23) FORM 1, (04) B. 1.(f)
10300 TORRE AVENUE
(24) FORM 1, (04) B. 2.(f)
8 097
CUPERTINO, CA 95014
(25) FORM 1, (04) C. 1.(f)
Type of Claim
(26) FORM 1, (04) C. 2.(f)
(03)
(09) Reimbursement
(27) FORM 1, (06)
10
(28) FORM 1, (07)
810
(04)
(10) Combined
(29) FORM 1, (09)
(05)
(11) Amended
Fiscal Year of Cost
(06)
(12)
01
(30) FORM 1, (10)
Total Claimed Amount
(07)
(13) $8,907
(31)
Less: 10% Late Penalty (refer to attached Instructions)
(14)
(32)
Less: Prior Claim Payment Received
(15)
(33)
Net Claimed Amount
(16) $8,907
(34)
Due from State
(08)
(17) $8,907
(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 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 a ,-�
Telephone Number ((4- J
'
.1 (.iG.'�f._.
Email Address C.I. _;' Lvl C'i, r ,s
Type or Print Name and Title of Authorized Signatory
0 J
(38) Name of Agency Contact Person for Claim
Telephone Number
Email Address
Name of Consulting Firm / Claim Preparer
Telephone Number (91 b) 797-4883
DAVID WELLHOUSE & ASSOCIATES (DWA)
Email Address dwa—renee@surewestnet
Local Mandated Cost Manual
Form FAM-27 (Revised 10/17)
PROGRAM
264
PEACE OFFICER PERSONNEL RECORDS:
UNFOUNDED COMPLAINTS AND DISCOVERY
CLAIM SUMMARY
FORM
1
(01) Claimant
CITY OF CUPERTINO
(02)
Fiscal Year
2016/2017
(03) Department
Direct Costs
Object Accounts
(04) Reimbursable Activities
(a) Salaries
(b)
Benefits
(c)
Materials
and
Supplies
(d)
Contract
Services
(e)
Fixed
Assets
(f)
Total
A. Notice to Peace Officers
1. Provide Immediate Notice to Officer
B. Record Retention
1. Retain Complaints and Reports for 3 More
Years
2. Maintain Separate Files
$8,097
$8,097
C. Notice to Complaining Parties
1. Provide a Copy of Complaint to
Complainant
2. Provide Written Notification to Complainant in 30 days
$0
(05) Total Direct Costs
Indirect Costs
$8,097
$8,097
(06) Indirect Cost Rate
[From ICRP or 10%]
10.00%
(07) Total Indirect Costs
[Refer to Claim Summary Instructions]
$810
(08) Total Direct and Indirect Costs
[Line (05)(f) + line (07)]
$8,907
Cost Reduction
(09) Less: Offsetting Revenues
(10) Less: Other Reimbursements
(11) Total Claimed Amount
[Line (08) - (line (09) + line (10)}]
$8,907
PROGRAM
PEACE OFFICER PERSONNEL RECORDS:
UNFOUNDED COMPLAINTS AND DISCOVERY
FORM
264
ACTIVITY COST DETAIL
2
(01) Claimant
(02) Fiscal Year
CITY OF CUPERTINO
2016/2017
(03) Reimbursable Activities: Check only one box per form to identify the activity being claimed.
A. Notice to Peace Officers B. Record Retention C. Notice to Complaining Party
❑ 1. Provide Immediate ❑ 1. Retain Complaints and ❑ 1. Provide a Copy of
Notice to Officer Reports for 3 More Complaints to
Years Complainant
El 2. Maintain Separate Files ❑ 2. Provide Written
Notification
(04) Description of Expenses
Object Accounts
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Employee Names, Job Classifications,
Hourly
Hours
Salaries
Benefits
Materials
Contracted
Fixed
Functions Performed,
Rate or
Worked or
and
Services
Assets
and Description of Expenses
Unit Cost
Quantity
Supplies
Lieutenant
$186.44
10
$1,864.40
Sergeant
$155.82
40
$6,232.80
Time spent for receipt of notice that discovery
or disclosure is sought of peace officer
personnel records and notificaiton of the
individual whose records are sought.
$8,097
(05) Total Subtotal Page: _ of — —