2005/10/12 Council Agenda Packet

3. Expenditures This Period Under `Categories' listed below, indicate either the actual expenditures, or estimated expenses if actual costs for these categories are not known. List the actual total expenditures on the last line of the following table. Local Fiscal Year Other Fiscal Year Funds to Date Funds to Date State CTR Fiscal Year Spent on Local Spent on Other Funds To Date CTR Funds CTR Funds Spent State CTR Activities Spent on Activities Spent on Since Last Funds Since Last CTR Since Last CTR Categories Report Spent Report Activities Report Activities Required Activities, $ $ $ $ $ $ including: 1. Notification of New Worksites 2. Administering CTR Surveys 3. Employer Annual Report Review 4. Exemptions and Modifications 5. Record Maintenance 6. Enforcement Employer Service Activities Employer Training $ $ $ $ $ $ Incentives $ $ $ $ $ $ Promotion and $ $ $ $ $ $ Marketing Guaranteed Ride $ $ $ $ $ $ Home Other(Specify) $ $ $ $ $ $ Totals $ $ $ $ $ 4. Jurisdiction(s) Contact Names,Address,and Phone Numbers Jurisdiction A John Who City of X PO Box 1234 X, WA 98000 Phone (206) 999-9999 5. List of contact information for effected worksites in the Jurisdiction. The information will be submitted in the electronic format approved by WSDOT. 6. Employer Annual Reports Approved During This Period Provide the name and worksite identification number for all employer annual reports accepted during this period. Attach a hard copy or electronic (disc) copy of all employer annual reports accepted by the jurisdiction during the quarter. If the jurisdiction accepted employer annual reports submitted via WSDOT's web-based reporting system, indicate the name and worksite identification number for each worksite report accepted. 7F Page 15 of 16 GCA4579