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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 />Pr ram Information <br />Service for the Month/Years of: <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 />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 0 0 <br />Summary <br />OCTA Monthly Contribution Amount: <br />City Monthly Contribution Amount: <br />Total Operation Cost for Month: <br />Source of City Contributions: <br />"Pleasespecify other trip es being rovided to seniors in this s ace: <br />Please provide the requested information and submit the completed form to OCTA. <br />Attention, Jessica OeakynelCommunity Transportation Coordinator. by email to jdeakynecacta.net or by FAX to (714)560 -5927. <br />—By the 16th 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 (09118108) Page 1 of 1 <br />25J -19 <br />