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AGREEMENT NO. C-1-2486 <br />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: <br />Program Name: <br />City or Organization: <br />Contact Person: <br />Contact Number: <br />Details <br />1 Trip Category I One-Way II Vehicle Service II Vehicle Service <br />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 -TO- J <br />Summary <br />OCTA Monthly Contribution Amount: <br />City Monthly Contribution Amount: <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 the requested information and submit the completed form to OCTA. <br />Attention: Jessica Deakyne/Community Transportation Coordinator, by email to jdeakyne@octa.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 />Comments: <br />TR-BO-086. doc (09/18108) Page 1 of 1