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ACTIA Bike/Ped Countywide Discretionary Fund Grant Agreement <br />LBE/SLBE REPORTING FORM <br />ACTIA No.: A04-0017 <br />Sponsor: Citv of San Leandro <br />Form musf be completed when the following is met: <br />• 1s ACTIA Grant Award over $25,000? If yes, continue. If no, you do not need to submit this report. <br />• Is $25,000 or more of the ACTIA Grant Award being used for all or part of a single Consultant contract? If yes, complete form. If no, you <br />do not need to submit this report. <br />Instructions: <br />• Complete form for the Prime Consultant and all Subconsultants that are a part of the contract. If you have multiple contracts that meet the <br />above requirements, you must report on all of these contracts. If multiple contracts, you may add additional tables for additional contracts. <br />• Submit once per year, with Progress Report #2 and Report #4 <br />Sponsor Name: <br />ACTIA Project #: <br />Progress Report #: <br />Date Submitted: <br />Does your Agency require or encourage LBE/SLBE in its Contracting <br />Procedures? <br />(Yes/ No) If yes, explain the requirements below or in an attachment. <br /> <br />Modifications Amount of <br />Previous <br />Current Total LBE SLBE <br />Consultant/Contractor Vendor <br />Full Address Contract <br />to this ACTIA <br />Invoice to <br />Invoice to Invoiced to Certified? Certified? <br />Name Tier Amount ($) <br />amount {+/_) funds in <br />ACTIA <br />ACTIA Date (to (Yes, No, (Yes, No, <br /> Contract ACTIA) Unk) Unk) <br /> Prime <br /> Sub <br /> Sub <br /> Sub <br /> TOTAL <br />Project Manager's Assurance: <br />I hereby certify that the information included here is <br />true and accurate. <br />Signature <br />Date <br />F:AACTIA\Prog»ms\Bicycle and Pcdestnan\Ctywidc Fund Progiam`~,Funded Pi~ujects -Cycle 03-04\San Leandro Slough Bridge_SL~~Agrcemcnt_A04-0017_SL Bridgc.DOC Page 15 of I S <br />