Payment Request (Rev 04/25/2022)
Request No.
From To
Amount
From To
Recipient EIN
Expenses Expenses Budget
Description Budget This Period To Date Balance
Direct Labor $0.00 $0.00
Fringe Benefits $0.00 $0.00
Travel/Mileage $0.00 $0.00
Equipment/Materials (Lead Only) $0.00 $0.00
Subcontractor/Consulting $0.00 $0.00
Other (Describe) $0.00 $0.00
Indirect Costs/G&A $0.00 $0.00
Total $0.00 $0.00 $0.00 $0.00
Less amount to be paid directly to third party
Net amount payable to voucher recipient $0.00
Date
Phone
Date
Project Manager Date
Type or Print name and Title
CALSTART Use Only
Amount Authorized:
CMO Contract No. Receipt DUNS
[Voucher Agreement number] ##-###-#### ##-#######
[Address 2]
[City, State, Zip]
$ 0.00
CALSTART Approval
Reviewed by
By signing, I certify to the best of my knowledge and belief that this report is correct and complete and all outlays and obligations are for the purposes set forth in the voucher agreement.
Signature of Certifying Officer
04/25/2024
Billing Period
Organization/Tribe Information Approved Project Term
[Organization/Tribe] 01
[Address 1]
([KLELW,
Employee Name Job Classification / Title
Hourly Labor
Rate
Billable
Labor
Hours
Reimbursable
Direct Labor
Expenses
Project Milestone
Achieved
0.000.000.000.000.000.000.000.000.000.000.000.000.00
0.00 - $ Hourly Direct Labor Totals
Agreement Number: [Voucher Agreement number]Payment Request Number:Period covered by this request: [MM/DD/YYYY - MM/DD/YYYY] Miles Rate Mileage
0.00 0.000.00 0.000.00 0.000.00 0.000.00 0.000.00 0.000.00 0.000.00 0.000.00 0.000.00 0.000.00 0.00
0.00 0.00 Totals
Total Billed
Agreement Number: [Voucher Agreement number]Payment Request Number:Period covered by this request: [MM/DD/YYYY - MM/DD/YYYY] Date From/To
Participants/Purpose/Project Milestone Achieved Travel
Mileage
Other
0.00 0.00 0.00
Match/
Cost Share
Agreement Number: [Voucher Agreement number]Payment Request Number:Period covered by this request: [MM/DD/YYYY - MM/DD/YYYY] Date Organization/Description
Purpose/Project Milestone Achieved Reference Amount Billed Totals
Date:
# Model Year GVWR VIN # Cost Paid
CMO EligibleReimbursement Amount*
123456789101112131415
TOTAL $0.00
Parent Company (if any):
A. MOTOR VEHICLE FORM
DATE: Payment Request Number: Voucher Agreement #: Lead Applicant (Awardee):
MOTOR VEHICLE PURCHASER/LESSEE INFORMATION:
Purchaser Contact Name: Company Name / Entity:Name of Lessor, if capital is a lease: Vehicle Domicile Address: City, State, Zip Code: 5. I have reviewed and reaffirm my obligation to adhere to the Terms and Conditions of the Voucher Agreement and CMO Implementation Manual.
Purchaser Phone: Purchaser E-mail:
TIN:
CONFIRMATION OF COMPLETION OF REDEMPTION CHECKLIST
1. I verify that I have submitted all items identified in the Redemption Checklist.2. The vehicle, vehicle price, and vehicle purchaser information on this form are true and correct.
3. The vehicle has been purchased and the information on this form is true and correct.4. The vehicle identified on this form has been delivered to my organization and is under their possession in accordance with the voucher agreement.
I certify under penalty of perjury that the information provided is accurate.
Name of Vehicle Purchaser/Lessee Representative:Signature of Vehicle Purchaser/Lessee:
MOTOR VEHICLE INFORMATION (add more rows as needed):
Manufacturer
reimbursement amount for each line item is the lesser of the actual cost or maximum reimbursement amount listed in Section E.1. For example, if the maximum vehicle reimbursement amount listed in Section E.1. is up to $60,000 but the actual vehicle cost was $53,450, then the eligible reimbursement amount is $53,450. Implementation Manual: https://www.cleanmobilityoptions.org/implementation-manual/ Date:
# Model Year Class 1 or Class 2 Serial Number Cost Paid CMO EligibleReimbursement Amount*
123456789101112131415
TOTAL $0.00
Parent Company (if any):
B. MICROMOBILITY DEVICES FORM
DATE: Payment Request Number: Voucher Agreement #: Lead Applicant (Awardee):
MICROMOBILITY DEVICES PURCHASER/LESSEE INFORMATION:
Purchaser Contact Name: Company Name / Entity:Name of Lessor, if capital a Vehicle Domicile Address: City, State, Zip Code: 5. I have reviewed and reaffirm my obligation to adhere to the Terms and Conditions of the Voucher Agreement and CMO Implementation Manual.
Purchaser Phone: Purchaser E-mail:
TIN:
CONFIRMATION OF COMPLETION OF REDEMPTION CHECKLIST
1. I verify that I have submitted all items identified in the Redemption Checklist.2. The bicycle/scooter, price, and purchaser information on this form are true and correct.3. The bicycle/scooter has been purchased and the information on this form is true and correct.4. The bicycle/scooter identified on this form has been delivered to my organization and is under their possession in accordance with the voucher agreement.I certify under penalty of perjury that the information provided is accurate.
MICROMOBILITY DEVICES INFORMATION (add more rows as needed):
Signature of Micromobility Devices Purchaser/Lessee:Name of Micromobility DevicesPurchaser/Lessee Representative:
Manufacturer
eligible reimbursement amount for each line item is the lesser of the actual cost or maximum reimbursement amount listed in Section E.1. For example, if the maximum vehicle reimbursement amount listed in Section E.1. is up to $3,500 but the actual vehicle cost was $3,350, then the eligible reimbursement amount is $3,350. Implementation Manual: https://www.cleanmobilityoptions.org/implementation-manual/ Payment Request #: Voucher Agreement #: Lead Applicant (Awardee):
Date:
#
Category (EVSE, Bike, Scooter, Solar PV, Hydrogen) Manufacturer Model Year Serial Number Installation Site Location (Address) Cost Paid CMO EligibleReimbursement Amount*
123456789101112131415
TOTAL $0.00
Purchaser Contact Name:
C. INFRASTRUCTURE FORM
DATE:
INFRASTRUCTURE PURCHASER/LESSEE INFORMATION:
Company Name / Entity:Parent Company (if any):Name of Lessor, if capital is a lease: Vehicle Domicile Address: City, State, Zip Code: Purchaser Phone: Purchaser E-mail:
TIN:
CONFIRMATION OF COMPLETION OF REDEMPTION CHECKLIST
1. I verify that I have submitted all items identified in the Redemption Checklist.
Infrastructure Item
2. The infrastructure, infrastructure price, and infrastructure purchaser information on this form are true and correct.3. The infrastructure has been purchased and the information on this form is true and correct.4. The infrastructure identified on this form has been delivered to my organization and is under their possession in accordance with the voucher agreement.5. The infrastructure identified on this form has been installed in approved sites.6. I have reviewed and reaffirm my obligation to adhere to the Terms and Conditions of the Voucher Agreement and and CMO Implementation Manual.I certify under penalty of perjury that the information provided is accurate.
Name of Infrastructure Purchaser/Lessee Representative:Signature of Infrastructure Purchaser/Lessee:
INFRASTRUCTURE INFORMATION (add more rows as needed):
*Eligible CMO infrastructure reimbursement amounts are listed in the Implementation Manual and must be consistent with the approved CMO voucher budget. The eligible reimbursement amount for each line item is the lesser of the actual cost or maximum reimbursement amountlisted in Section E.1. For example, if the eligible reimbursement amount for an item is $30,000 and the actual cost is $24,340, then the eligible reimbursement amount is $24,340. Implementation Manual: https://www.cleanmobilityoptions.org/implementation-manual/