JUNE2016INSTRUCTIONS FOR THE REIMBURSEMENT REQUEST FORM (CP73)
The REQUEST FOR PAYMENT FROM CHIPS REIMBURSEMENT PROGRAM (form CP73) is on the back of these instructions. If you need more than one REQUEST FOR PAYMENT FROM CHIPS REIMBURSEMENT PROGRAM form for a quarterly reimbursement, type at the top of each whether the form is 1 of 1, 1 of 2, 2 of 2, etc. Only forms entered on-line and mailed to your CHIPS Representative will be accepted.
A. MUNICIPAL DESCRIPTION: type on-line the name of the municipality and the six digit NYSDOT municipal code.
B. PROJECT LISTING
1. Type on-line the route number or name of the specific street, highway, bridge, or “other” project for which reimbursement is being requested. NOTE: If reference is made to “various” streets, traffic control devices, etc., you must indicate “see attached list” and then attach a list of each street, traffic control device, etc., along with itsproject cost/reimbursement requested.
2. Type on-line the location of the project by identifying both the “from” (where the project begins) and the “to” (where the project ends). This requirement also applies to any projects in an “attached list”. If project type is “Other” and it is an equipment purchase, describe the equipment next to “Route/Name/Other.”
3. Select on-line the one project type which best describes the major component of the project. The six standard project type definitions are: (1) Highway Resurfacing; (2) Highway Reconstruction; (3) Traffic Control Devices; (4) Bridge/ Culvert Rehabilitation; (5) Bridge/Culvert Replacement; and (6) Other (specify actual project).
4.Select on-line the one project sub type which best describes the work done under project type.
5.Type on-line the actual or estimated total project cost for each project for which you are requesting reimbursement under a particular quarterly payment. Refer to the first paragraph of the “Eligible Project Costs and Payment Reimbursements” discussion on p. 4 of the Program Guidelines and be aware that the “total project cost” for a project often exceeds its requested reimbursement for a particular quarterly payment.
6.Type on-line the reimbursement requested for each project. If the requested amount represents the final CHIPS Capital reimbursement for a project, click the “yes final payment” circle; if you expect the requested amount for a particular project to be followed by additional payment requests in the current State Fiscal Year for that project, click the “no final payment” circle.
7.Do not type in a figure for Total Amount Claimed. This total will be automatically calculated at the bottom of each form after individual project entries have been completed.
C.CERTIFICATION
1. Select on-line the expenditure eligibility period (month/day/year - month/day/year) for which you are requesting reimbursement, as follows:
a. For expenditures made during the current State Fiscal Year (SFY) from any CHIPS Capital “rollover” balances and/or the current SFY CHIPS Capital apportionment, the expenditure eligibility period will be simply the expenditure eligibility dates specified in the quarterly NYSDOT “payment” letters; and/or
b. For unreimbursed expenditures made from a previous SFY CHIPS Capital “rollover” balance, reimbursement eligibility is limited to only those local expenditures actually made within an 18 month period prior to the currently scheduled quarterly payment date specified in the most recent NYSDOT payment letter. Do not select dates which cross state fiscal years (SFY); a separate form must be submitted for each April 1 – March 31 SFY for which expenditures are incurred.
2. The required certification statement should be signed by the same municipal official (in most cases, the highway superintendent) whose name is printed at the bottom of the CP73 form.
3. Type on-line the phone number of the municipal official who signs the CP73 form.
4. Select on-line the date (month/day/year) on which this Certification Statement was signed. This signature date should fall within or after the expenditure dates which you entered on the CP73(s).
5. Type on-line the e-mail address (if applicable) of the municipal official who signs the CP73 form.
6. Use the “Print, Sign, & Mail to Regional CHIPS Rep” button to print the form(s) only after all required info has been entered. Sign the completed form(s), make one copy for your files, and then mail to your NYSDOT Regional CHIPS Representative.