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AGREEMENT NO. C -1 -2486 <br />Senior Mobility Program Monthly Reporting Form EXHIBIT C <br />Monthly Reporting E -Form <br />Service for the Month/Years of: <br />Program Name: <br />City or Organization: <br />Contact Person: <br />Contact Number: <br />Details <br />I. <br />Trip Category I One-Way Vehicle Service I Vehicle Service <br />Passenger Trip Hours Mlles <br />Nutrition Trips: <br />Medical trips: 11 11 <br />Shopping trips: <br />Surnmary <br />OCTA Monthly Contribution Amount <br />City Monthly Contribution Amount: 11 1 <br />Total Operation Cost for <br />Source of City <br />"Please specify other trip types be'ng provided to senors in thi spa <br />Homo pruvme me roquestev ammeimn and submit ire completed form to OCTA. <br />Attonton Jessica DeakynelCommunity Transportation Coordinator, by email to ideakyneCoula.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 -5602 if you have any questions or require assistance with the completion of this form, <br />TR- 9D- 086.doc (09/16108) Page 1 of 1 <br />19D -18 <br />