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CMA TIP Fund Transfer Agreement No. CMATIP-008 <br />CMA TIP Project No. 008 <br />Widen Marina Boulevard — Alvarado to San Leandro <br />APPENDIX C <br />REQUEST FOR REIMBURSEMENT OF FUNDS <br />SAMPLE FORM <br />(Submit Requests on SPONSOR letterhead) <br />Project SPONSOR: City of San Leandro <br />Project Title: Widen Marina Boulevard — Alvarado to San Leandro <br />CMA TIP Project No: 008 <br />Total CMA TIP funds programmed to the PROJECT: <br />Total of previous reimbursement requests: <br />Balance available for this request: <br />Amount of this Request *: <br />$ 150,000 <br />k <br />* Please attach supporting documentation for expenditures to be reimbursed. Costs should be <br />segregated by the eligible activities shown in Appendix A. If there are matching fund <br />requirements stipulated in Appendix B, supporting documentation is required for both costs to <br />be reimbursed by the CMA TIP and costs to be funded by matching funds. <br />To the best of my knowledge, the above information is true and correct and I am authorized to <br />request this reimbursement of funds. <br />Name & Title: <br />Signature: <br />Date: <br />Do not write below this point. To be completed by the CMA only <br />Approval: Amount $: <br />Check Number: Check Date: <br />Comments: <br />