20-007 David Wellhouse & Associates, Inc., State Mandated Cost Reimbursement Claims FY 2019-2020(2)State of California
State Controller's Office Mandated Cost Manual for Local Agencies
DOMESTIC VIOLENCE ARREST For State Controller Use Only
Program
POLICIES AND STANDARDS (19) Program Number 00167
CLAIM FOR PAYMENT FORM (20) Date Filed 167
(21) LRS Input
(01} Claimant Identification Number 9843231 Reimbursement Claim Data
(02) Claimant Name City of Cupertino (22) FORM 1, (04) (a)
County of Location Santa Clara (23) FORM 1, (04) (b)
Street Address or P.O . Box and Suite 10300 Torre Avenue (24) FORM 1, (06)
City , State, and Zip Code Cupertino, CA 95014 (25) FORM 1, (07) A (g)
(03) Type of Claim (26) FORM 1, (07) B. (g)
(04) (09) Reimbursement 0 (27) FORM 1, (07) C. (g)
(05) (10) Combined (28) FORM 1, (09)
(06) (11) Amended (29) FORM 1, (10)
(07) (12) Fiscal Year of Cost 2019/2020 (30) FORM 1, (12)
(08) (13) Total Claimed Amount (31) FORM 1, (13)
(14) Less: 10% Late Penalty (32)
(15) Less: Prior Claim Payment Received (33)
(16) Net Claimed Amount (34)
(17) Due from State (35)
(18) Due to State (36)
(37) CERTIFICATION OF CLAIM
In accordance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officer
authorized by the local agency to file mandated cost claims with the State of California for this program, and certify
under penalty of perjury that I have not violated any of the provisions of Article 4, Chapter 1 of Division 4 of Title 1 of
the Government Code.
I further certify that there was no application other than from the claimant, nor any grant(s) or payment(s)
received for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of
services of an existing program . All offsetting revenues and reimbursements set forth in the parameters and
guidelines are identified, and all costs claimed are supported by source documentation currently maintained by the
claimant.
The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the
attached statements .
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature of Authorized Officer Date Signed
x ~ .J .... . ,,. -~ Telephone Number ( 408) 777 -3225
,-r J
Type or Print Name and Title of Authorized Signatory Email Address kirstens(@cui;;1ertino .org
Kirsten Squarcia, City Clerk
(38) Name of Agency Contact Person for Claim Telephone Number
I Email Address
Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883
David Wellhouse & Associates, Inc Email Address dwa-renee(@surewest.net
Revised 9/2020
State of California
State Controller's Office Mandated Cost Manual for Local Agencies
DOMESTIC VIOLENCE ARRESTS AND VICTIM For State Controller Us e Only
Program ASSISTANCE CLAIM FOR PAYMENT FORM (19) Program Number 00274
(20) Date Filed 274
(21) LRS Input
(01) Cla imant Identification Number 9843231 Reimbursement Claim Data
(02) Cla imant Name City of Cupertino (22) FORM 1, (04) A. 1 . (f)
County of Location Santa Clara (23) FORM 1, (04) A. 2 . (f)
Street Address or P.O. Bo x and Suite 10300 Torre Avenue (24) FORM 1, (04) A. 3. (f)
City, State, and Zip Code Cupertino, CA 95014 (25) FORM 1, (04) B. 1 (f)
(03) Type of Claim (26) FORM 1, (06)
(04) (09) Reimbursement 0 (27) FORM 1, (07)
(05) (10) Combined (28) FORM 1, (09)
(06) (11) Amended (29) FORM 1, (10)
(07) (12) Fiscal Year of Cost 2019/2020 (30)
(08) (13) Total Claimed Amount (31)
(14) Less: 10% Late Penalty (32)
(15) Less : Prior Claim Payment Received (33)
(16) Net Claimed Amount (34)
(17) Due from State (35)
(18) Due to State (36)
(37) CERTIFICATION OF CLAIM
In accordance with the provisions of Government Code sections 17560 and 17561 , I certify that I am the officer
authorized by the local agency to file mandated cost claims with the State of California for this program, and certify
under penalty of perjury that I have not violated any of the provisions of Article 4, Chapter 1 of Division 4 of Title 1
of the Government Code.
I further certify that there was no application other than from the claimant, nor any grant(s) or payment(s)
received for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of
services of an existing program . All offsetting revenues and reimbursements set forth in the parameters and
guidelines are identified , and all costs claimed are supported by source documentation currently maintained by the
claimant.
The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the
attached statements .
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature of Authorized Officer Date Signed
X Jc;;~~ hA --. ,1 Telephone Number (408) 777-3225
_,~ -c;.,.. rr -,
Type or Print Name and Title"of Authorized Signatory Email Address kirstens@cu12ert ino .org
Kirsten Squarcia, City Clerk
(38) Name of Agency Contact Person for Claim Telephone Number
I Email Address
Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883
David Wellhouse & Associates, Inc Email Address dw a-renee@su rewest.net
Revised 9/2020
State of California
State Controller's Office Mandated Cost Manual for Local Agencies
RAPE VICTIMS COUNSELING CENTER NOTICE For State Controlle r Use Only
CLAIM FOR PAYMENT FORM (19) Program Number 00127 Program
(20) Date Filed 127
(21) LRS Input
(01) Claimant Identification Number 9843231 Reimbursement Claim Data
(02) Claimant Name City of Cupertino (22) FORM 1, (03)
County of Location Santa Clara (23) FORM 1, (04) 1. a . (e)
Street Address or P.O . Box and Su ite 10300 Torre Avenue (24) FORM 1, (04) 1. b. (e)
City, State, and Zip Code Cupertino, CA 95014 (25) FORM 1, (04) 2 . a . (e)
(03) Type of Claim (26) FORM 1, (04) 2 . b. (e)
(04) (09) Reimbursement 0 (27) FORM 1, (06)
(05) (10) Combined (28) FORM 1, (07)
(06) ( 11) Amended (29) FORM 1, (09)
(07) ( 12) Fiscal Year of Cost 2019/2020 (30) FORM 1, (10)
(08) (13) Total Claimed Amount (31)
(14) Less : 10% Late Penalty (32)
(15) Less : Prior Claim Payment Received (33)
(16) Net Claimed Amount (34)
(17) Due from State (35)
(18) Due to State (36)
(37) CERTIFICATION OF CLAIM
In accordance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officer
authorized by the local agency to file mandated cost claims with the State of California fo r this program, and certify
under penalty of perjury that I have not violated any of the provisions of Article 4, Chapter 1 of Division 4 of Title 1 of
the Government Code .
I further certify that there was no application other than from the claimant, nor any grant(s) or payment(s)
received for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of
services of an existing program. All offsetting revenues and reimbursements set forth in the parameters and
guidelines are identified , and all costs claimed are supported by source documentation currently maintained by the
claimant.
The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the
attached statements.
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature of Authorized Officer Date Signed
x~/4 ,., -~,,~I Telephone Number (408) 777-3225
Type or Print Name and Titfe/of Authorized Signatory Email Address kirstens@cuQert i no.o rg
Kirsten Squarcia, City Clerk
(38) Name of Agency Contact Person for Claim Telephone Number
I Email Address
Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883
David Wellhouse & Associates, Inc Email Address dwa-re ne e @.s u rewest. net
Revised 9/2020
State of California
State Controller's Office Mandated Cost Manual for Local Agencies
PEACE OFFICERS For State Controller Use Only
Program PROCEDURAL BILL OF RIGHTS (19) Program Number00187
CLAIM FOR PAYMENT FORM (20) Date Filed 187
(21) LRS Input
(01) Claimant Identification Number 9843231 Reimbursement Claim Data
(02) Claimant Name City of Cupertino (22) FORM 1, (04)
County of Location Santa Clara (23) FORM 1, (05)
Street Address or P.O. Box and Suite 10300 Torre Avenue (24) FORM 1, (06)(A)(g)
C ity, State , and Zip Code Cupertino, CA 95014 (25) FORM 1, (06)(B)(g)
(03) Type of Claim (26) FORM 1, (06)(C)(g)
(04) (09) Reimbursement 0 (27) FORM 1, (06)(D)(g)
(05) (1 O) Combined (28) FORM 1, (08)
(06) (11) Amended (29) FORM 1, (09)
(07) (12) Fiscal Year of Cost 2019/2020 (30) FORM1,(11)
(08) (13) Total Claimed Amount (31) FORM 1, (12)
(14) Less : 10% Late Penalty (32)
(15) Less : Prior Claim Payment Received (33)
(16) Net Claimed Amount (34)
(17) Due from State (35)
(18) Due to State (36)
(37) CERTIFICATION OF CLAIM
In accordance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officer
authorized by the local agency to file mandated cost claims with the State of California for this program, and certify
under penalty of perjury that I have not violated any of the provisions of Article 4, Chapter 1 of Division 4 of Title 1
of the Government Code .
I further certify that there was no application other than from the claimant, nor any grant(s) or payment(s)
received for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of
services of an existing program . All offsetting revenues and re imbursements set forth in the parameters and
guidelines are identified, and all costs claimed are supported by source documentation currently maintained by the
claimant.
The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the
attached statements .
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature of Author ized Officer Date Signed
X ~~--,, ~ J,,,
V -I" V
,-,. ~J_ Telephone Number (408) 777-3225
Type or Print Name and Title of Authorized Signatory Email Address k irstens@cuge rt i no . e rg
Kirsten Squarcia, City Clerk
(38) Name of Agency Contact Person for Claim Telephone Number
I Email Address
Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883
David Wellhouse & Associates, Inc Email Address dwa-re neel@su rewest. net
Revised 9/2020
State of California
State Controller's Office Mandated Cost Manual for Local Agencies
ADMINISTRATIVE LICENSE For State Controller Use Only
SUSPENSION -PER SE (19) Program Number 00246 Program
CLAIM FOR PAYMENT FORM (20) Date Filed 246
(21) LRS Input
(01) Claimant Identification Number 9843231 Reimbursement Claim Data
(02) Claimant Name City of Cupertino (22) FORM 1, (04) A . 1. (h)
County of Location Santa Clara (23) FORM 1, (04) A. 2. (h)
Street Address or P.O. Box and Suite 10300 Torre Avenue (24) FORM 1, (04) B. 1. (h)
City, State, and Zip Code Cupertino, CA 95014 (25) FORM 1, (06)
(03) Type of Claim (26) FORM 1, (07)
(04) (09) Reimbursement 0 (27) FORM 1, (09)
(05) (10) Combined (28) FORM 1, (10)
(06) (11) Amended (29)
(07) (12) Fiscal Year of Cost 2019/2020 (30)
(08) (13) Total Claimed Amount (31)
(14) Less: 10% Late Penalty (32)
(15) Less: Prior Claim Payment Received (33)
(16) Net Claimed Amount (34)
(17) Due from State (35)
(18) Due to State (36)
(37) CERTIFICATION OF CLAIM
In accordance with the provisions of Government Code sections 17560 and 17561, I certify that I am the officer
authorized by the local agency to file mandated cost claims with the State of California for this program, and certify
under penalty of perjury that I have not violated any of the provisions of Article 4, Chapter 1 of Division 4 of Title 1 of
the Government Code.
I further certify that there was no application other than from the claimant, nor any grant(s) or payment(s)
received for reimbursement of costs claimed herein and claimed costs are for a new program or increased level of
services of an existing program . All offsetting revenues and reimbursements set forth in the parameters and
guidelines are identified, and all costs claimed are supported by source documentation currently maintained by the
claimant.
The amount for this reimbursement is hereby claimed from the State for payment of actual costs set forth on the
attached statements.
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature of Authorized Officer Date Signed
X k~A0-:-.J L> ,~ --_, I Telephone Number (408) 777-3225
17 ---,;' -, J -,-
Type or Print Name and Title of Authorized Signatory Email Address kirstens@cuQertino .org
Kirsten Squarcia, City Clerk
(38) Name of Agency Contact Person for Claim Telephone Number
I Email Address
Name of Consulting Firm/Claim Preparer Telephone Number (916) 797-4883
David Wellhouse & Associates, Inc Email Address dwa-renee(@su rewest.net
Revised 9/2020