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vim <br />kAnnthly Rannrfinn F_Fnrm <br />AGREEMENT NO. C-1-2492 <br />FA Senior Mobility Program Monthly Reporting Form EXHIBIT C <br />Monthly Reporting E-Form <br />OCTA <br />Program Information' <br />Service for the Month,Years of: D <br />Program Name: <br />City or Organization: <br />Contact Person: <br />Contact Number: <br />Details <br />Trip Category One-Way Vehicle Service Vehicle Service <br />11 Passenger Trip Hours Miles <br />Nutrition Trips: <br />Medical trips: <br />Shopping trips: <br />Other trips: <br />(Please specify trip type below") <br />Totals: 0 011 <br />0 <br />Summary <br />OCTA Monthly Contribution Amount: 11 <br />City Monthly Contribution Amount: 11 <br />Total Operation Cost for Month: <br />Source of City Contributions: <br />`"Please specify other trip types being provided to seniors in this space: <br />Please provide 0e requested information and submlt the Completed form to OCTA. <br />Allentlon: Jessica Deakyne/Community Transportation Coordinator, by email to yleakyne§oda.net or by FAX to (714)560-5927. <br />"'By the 15th day of the month following the reporting month"' <br />Please contact Jessica Deakyne at (714) 560-5802 if you have any questions or require assistance with the completion of this form, <br />TR-80-086. Coc (09119/08) Page 1 of 1