DateofInvoice:

EXHIBIT5-ESAMPLE“STIPORATPPROJECT”FEDERALINVOICE

(PrepareonLetterheadofLocalAgency)

Name,DistrictLocalAssistanceEngineer:DepartmentofTransportation

DistrictLocalAssistanceStreet/P.O.Box:

City,CA,ZipCode:

BillingNumber:1,2……,orFinal

InvoiceNumber:LocalAgency’sInvoiceNumber

Federal-AidProjectNumber:PrefixProjectNumber(Fed.Agreement#)

TaxIdentificationNumber:AgencyIRSIDNumber

DateProjectAcceptedbyCity/County:FinalDateor“Ongoing”ifnotFinal

ProjectLocation:ProjectLimits

ExpenditureAuthorizationorAdvantageProjectNumber:

ReimbursementforFederalfundsisclaimedpursuanttoLocalAgency-StateAgreementNo._,ProgramSupplementNo. ,executedondate .

EnvironmentalStudiesPermits / PS&E / ConstructionEngineering / Construction
Non-Infrastructure / Total
FederalAppropriationsCode / Q24/33D / Q24/33D / Q24/33D / Q24/33D / Q24/33D
FederalAuthorizationDate / 5/12/14 / 5/12/14 / 6/10/14 / 6/10/14
Federal/StateParticipatingCostsFrom / 5/15/14 / 6/15/14 / 6/15/14 / 6/15/14
To / 8/15/14 / 8/15/14 / 8/15/14 / 8/15/14
TotalIndirectCoststoDate / $825.00**** / $1,865.50**** / $2,690.50**** / $3,640.50**** / $9,032.50
TotalDirectCoststoDate / $4,000.60 / $8,400.30 / $8,290.00 / $150,652.00 / $171,342.90
LessRetention / ($20,000.00)* / ($20,000.00)
LiquidatedDamages / $0.00** / $0.00
NonparticipatingCosts / ($350.00) / ($840.00) / ($1,200.00) / ($16,000.00) / ($18,390.00)
TotalFederalParticipatingCoststodate / $4,475.60 / $9,425.80 / $9,780.50 / $114,652.00 / $138,333.90
LessParticipatingCostsonPreviousInvoice / $2,120.95 / $6,350.20 / $0.00 / $98,231.00 / $106,702.15
ChangeinParticipatingCosts / $2,354.65 / $3,075.60 / $9,780.50 / $16,421.00 / $31,631.75
FederalReimbursementRatio / 88.53 / 88.53 / 88.53 / 88.53
StateReimbursementRatio / 0.00 / 0.00 / 11.47 / 11.47
AmountofthisClaim / $2,084.57*** / $2,722.82*** / $9,780.50*** / $16,421.00*** / $31,008.89
TOTALINVOICEAMOUNT / $31,008.89

INDIRECTCOSTCALCULATIONS****

EnvironmentalStudiesPermitsIndirectCosts:

FiscalYear2012-2013 / FiscalYear2013-2014
DirectCostBaseExpense / $1,944.00 / $673.82
ApprovedIndirectCostRate / 31% / 33%
Subtotal**** / $602.64 / $222.36

TotalIndirectCoststoDateforEnvironmentalStudiesPermits$825.00(thisAmountiscarriedtothefrontoftheinvoiceundertheEnvironmentalStudiesPermitscolumn)

PS&EIndirectCosts:

FiscalYear2012-2013 / FiscalYear2013-2014
DirectCostBaseExpense / $4,756.23 / $1,185.07
ApprovedIndirectCostRate / 31% / 33%
Subtotal**** / $1,474.43 / $391.07

TotalIndirectCoststoDateforPS&E$1,865.50(thisAmountis carried tothefrontoftheinvoiceunderthePS&Ecolumn)

ConstructionEngineeringIndirectCosts:

FiscalYear2012-2013 / FiscalYear2013-2014
DirectCostBaseExpense / $6,000.00 / $2,516.67
ApprovedIndirectCostRate / 31% / 33%
Subtotal**** / $1,860.00 / $830.50

TotalIndirectCoststoDateforConstructionEngineering$2,690.50(thisAmountiscarriedtothefrontoftheinvoiceundertheConstructionEngineeringcolumn)

Non-InfrastructureIndirectCosts:

FiscalYear2012-2013 / FiscalYear2013-2014
DirectCostBaseExpense / $8,000.00 / $3,516.67
ApprovedIndirectCostRate / 31% / 33%
Subtotal**** / $2,480.00 / $1160.50

TotalIndirectCoststoDateforNon-Infrastructure(Only)$3,640.50(thisAmountiscarriedtothefrontoftheinvoiceundertheNon-Infrastructurecolumn)

Icertifythattheworkcoveredbythisinvoicehasbeencompletedinaccordancewithapprovedplansandspecifications;thecostsshowninthisinvoicearetrueandcorrect;andtheamountclaimed,includingretentionasreflectedabove,isdueandpayableinaccordancewiththetermsoftheagreement.

Signature,TitleandUnitofLocalAgencyRepresentativePhoneNo.Forquestionsregardingthisinvoice,pleasecontact:

NamePhoneNo.

*Total retention amountwithheldfromcontractor. Atthe end ofthe projectandafterallretention has been released,thisamountshouldbe zero.

**Show “liquidated damages”amounton finalinvoice.

***Pleaserounddownthefigurestothelowestcent.Federalrules donot allowroundingup.

****•Indirectcost forthisprojectequalsthedirect costbaseexpense(i.e.,direct salarieswages plusfringebenefits)forthisproject multiplied bythe approved indirectcostrate.

•Indirectcost reimbursementwillnotapplyto directcosts, i.e., paymentofconstruction contracts and rightofway purchases,not

included in the direct cost base.

•An indirectrate mustbe approvedbyCaltrans everyfiscalyeartobeused foronlythose costs incurredforthatyear.

•Non-Infrastructure IndirectCosts(only)are shown underthe Construction costcolumn.

AllotherIndirectCostsare shown undertheirrespective costcolumnforthe phase ofwork,i.e.EnvironmentalStudiesPermits,PS&E,and Construction Engineering.

NOTE: ForR/WAcquisition use Exhibit5-D

Distribution:Original 2copiesto DLAE