NYSDOT - FEDERAL PROGRAMS REIMBURSEMENT PROCESS
New York State Department of Transportation (NYSDOT)5311 Grantee:______
FEDERAL PROGRAMS REIMBURSEMENT PROCESSContract Number:_______ Requested Amount:$______
The following process applies to Grantees seeking reimbursement of federal and state shares, as applicable, for projects completed, or at levels of completion. A contract must be fully executed before federal and state share reports and invoices can be processed. Prompt and consistent reporting helps to insure that a Grantee will not experience a delay in payment. Grantees must provide the NYSDOT with all payment process information detailed in this document to ensure timely reimbursement. Information not applicable to the project should be marked N/A, incomplete information will be returned to the Grantee for completion and re-submission.
INSTRUCTIONS:
Complete the Project Information Section and Reimbursement Checklist below in their entirety. The project information section provides detailed information pertaining to the programs(s) sponsor, and project, the reimbursement is being requested for. The reimbursement checklist provides guidance for necessary documentation and certifications required to be submitted for reimbursement. After taking delivery of the equipment or services, complete, certify and submit this checklist along with all required documents necessary for reimbursement for the Federal and State shares of the project costs. Return all documentation to: NYSDOT, Public Transportation Bureau, 50 Wolf Rd POD 54, Albany NY 12232
PROJECT INFORMATION:
A / B / CPIN / Project Information / Vendor Name / Total Project Cost / Federal Share (80%) / State Share (10%) / Pmt Request (A+B)
TOTAL REQUEST
REIMBURSEMENT CHECKLIST:
REQUIRED FOR ALL REIMBURSEMENTS / *ADDITIONAL REQUIREMENTS FORROLLING STOCK PURCHASES
Obtain one (1) copy of the final vendor invoice. Equipment invoices should be itemized and Service invoices should detail completion percentages. / *Complete the enclosed “Post Delivery Certification of Compliance with Rolling Stock Purchases”; including the list of actual components and final assembly.
Obtain one (1) copy of the cancelled check issued to the vendor or other proof of payment. / *Complete the Bus Inventory Spreadsheet DOWNLOAD
Complete the enclosed “Equipment Record and Maintenance Plan” for all equipment purchased having a value of $5,000 or greater (not applicable to “Rolling Stock”). / *Complete Third Party Lease & Service Agreement. DOWNLOAD .
Procurement Checklist has been completed (this is required to advance payment)
CERTIFICATION:
I certify, on behalf of the applicant, that the equipment and/or services listed on the attached invoice(s) has been delivered
and been found to be acceptable.
______\____\____
Name and Title of Chief Elected Official or Authorized Official Signature Date
NYSDOT - FEDERAL PROGRAMS REIMBURSEMENT PROCESS
POST-DELIVERY CERTIFICATION OF
BUY AMERICA, SPECIFICATION REQUIREMENTS AND FMVSS COMPLIANCE
FOR ROLLING STOCK PURCHASES
1.BUY AMERICA: APPLICABLE ONLY FOR VEHICLE PURCHASES OVER $100,000 As required by Title 49 of the CFR, Part 663 - Subpart C, this certifies that the vehicles received ______(number & description) from______(manufacturer), meet the requirements of Section 165(b)(3) of the Surface Transportation Assistance Act of 1982, as amended. The Recipient or its appointed analyst (not the manufacturer or its agent) has reviewed documentation provided by the manufacture, which lists (1) the actual component and subcomponent parts of the buses identified by the manufacture, country of origin and cost; and (2) the actual location of the final assembly point for the buses, including a description of the activities that took place at the final assembly point and the cost of final assembly;
2.
SPECIFICATION REQUIREMENTS: As required by Title 49 of the CFR, Part 663 - Subpart C, after visually inspecting and road testing the contract buses, this certifies that the buses______(number and description) from ______(manufacturer) meet the contract specifications.
3.FMVSS: As required by Title 49 of the CFR, Part 663 - Subpart D, this certifies that the municipal corporation received from ______(manufacturer), at the post-delivery stage, a copy of the self-certification information stating that the vehicles ______(number and description) comply with the relevant Federal Motor Vehicle Safety Standards issued by the National Highway Traffic Safety Administration in Title 49 CFR Part 571.
-OR-
I have coordinated with the local State Department of Transportation vehicle Inspector and received their report as passing Part 720/721 of the Transportation Regulation which includes FMVSS.
______
Name and Title of Chief Elected or Authorized Official
______
SIGNATURE OF CHIEF ELECTED OR AUTHORIZED OFFICIAL
______
DATE
Equipment Record and Maintenance Plan
(Not Applicable to Rolling Stock)
All equipment and facilities with an acquisition value greater than $5,000 to be procured with federal funds must be accompanied by an “Equipment Record and Maintenance Plan” filled out entirely to qualify for reimbursement (one for each piece of equipment).
Rules and Regulations can be found at:
Grantee Name: ______Grantee Address: ______
Description of the asset: ______
Project Identification Number (PIN): ______Acquisition Date: _____/_____/_____
Cost: $ ______Useful Life: ______Percent Federal Participation______
Where a useful life policy has not been defined, the grantee, in consultation with NYSDOT, will establish duration through one of the following methods: Generally accepted accounting principles, Independent evaluation, Manufacturer’s estimated useful life, Internal Revenue Service guidelines, Industry standards, Grantee experience (The grantee’s independent auditor who needs to concur that the useful life is reasonable for depreciation purposes), orProven useful life developed at a Federal test facility.
Physical Location: ______
______
______
Use and Condition: ______
______
______
Asset Management Preventative Maintenance Plan:
A Preventative Maintenance Program is designed to be preventive rather than reactive; a strong preventive maintenance program effectively reduces overall maintenance costs by decreasing the number of unpredictable repairs. Please use this form for all equipment purchased with a value of $5,000 or more (excluding vehicles and large facilities).
Based on manufacturer’s recommendations and modified based on experience and the local conditions please provide the following timelines and practices that will be implemented to ensures equipment listed remain in safe operating condition.
1)Inspection Schedule (check one): Hourly ___, Weekly ___, Monthly ___, Quarterly ___, Semi-Annual ___, Annual ___
2)Organization Performing Maintenance: ______
3) Organization Overseeing Maintenance Activities: ______
4) Review Checklist: Check all activities that will be performed as part of your Asset Management Plan for listed equipment.
Physical Inspection: ___, Operations/Performance ___, Repair Order Route ___, Management Notification ___, Documentation ___
5) Grantee agrees toensure all cost of parts and repairs covered under warranty are recovered. Yes ___ No ___
I certify to the above Equipment Record and Maintenance Planas being accurate to the best of my knowledge and will be performed as stated:
______/____/____
Signature of Authorized Official Date