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<br />. , <br /> <br />'PPR-19-2007 14::1 <br /> <br />J:TA ''Fl. C'l"ll': <br /> <br />'n45605'?92 P. 14/14 <br />A'"'t~EEMENT NO, C.2.0148 <br />EX'iIBIT C <br /> <br />~!!!lIIi <br />:V:f ~~t;::";:;!lV <br /> <br />It:l,~Ti~:A <br /> <br />Senior Mobility Transportation Project <br />Monthly Reporting Form <br /> <br />S(~rvice for the monti, of: _..______.____ <br /> <br />Program Name: <br /> <br />~--,--_.--..._----'~--~--- <br /> <br />c;~: <br /> <br />__,._.---_,__.,...____________~_"__'W_ <br /> <br />Cor,;,act Person: <br /> <br />---~----~_.._~~-----~-_.~ <br /> <br />ConV.2ct Phone: <br /> <br />--~,-_...----~-- <br /> <br />... .'. ~~____...__..._"*..... _.,_____~,......... ...._ ,~. ,....____ .,.........n .... YOO____.........___ ___ .'" ----~ .. __ ._........... ,--..................... ...-..---. -..-.... --- <br /> <br />r <br />! <br /> <br />Trip catElgory <br /> <br />Number of <br />__passienger!'c. <br /> <br />Vehicle service <br />hours <br /> <br />-~~hicle se~ ice <br />miles <br /> <br />U~~.rition Trips <br /> <br />,'r ~.'~l':..;d i n~s <br />..~ .~--~.._- -~-_._- ------..----...- <br /> <br />: '3'1'Jocina Trips <br />'n_ ,..... -__.._.~___~_~_-_.._.._._ <br /> <br />Other Trips (Fleas. L <br /> <br />~~::It: type b~"W"):=I:~==,~=:~:~ <br /> <br />--'-~--'--'~~-'-'--~---- -----~---~-----~- <br /> <br />-_._-~'.__._-----_._'_.~ ----_.,.~-----~ <br /> <br />,'Ji",:.. ,;,pera'l;illg CI:ISt IFol' month: <br /> <br />$ -.-....--------- <br /> <br />$.__._~_..._._- <br /> <br />$---..-.-.---- <br /> <br />oeTA monthly contribll1:ion amounl:: <br />~"~:' Tnn~hl:t contributi,a,n amo,unt: <br /> <br />Source City Gont,'ibuticms _____..._,______________. <br />C.,rnrnents; <br /> <br />cTMle:e the information reqlJested ii' this form and fax the completed fo,'m to OCTA, Attention <br />: S U..partmHrlt at ('114) 56',).5914 by the IS" day of thr., monti', followlIlg Hie reporting month <br /> <br />F'lease contact tl'e Tmnsportl.ction Amai'1st ,II (1'14) 56D-5425 if you ha>lEJ any quest ons or requi,e <br />"ssistance with the CCrnplfJtion of thi'; form. <br /> <br />rn--- ----.-.---.-.---...------~--------- ------J <br />' . ," "'zs':! spodfy Cither trir.' tYPf!S beh'lD prov'c:ed to senlcors ill this sp.lce <br /> <br /> <br />L____ -. - .-..-.-.------ --- .. ---..-- ..-..- -.. .. ------.. <br /> <br />L:\CGlmm\REBECC/\\1 VVc'~king\Sen cr Mollilt; ':~9rtI8!~t!mtsrV4.G2tl14-1 c: j(JJ; <br /> <br />TOT'lL P.14 <br />