Fillable ESHP Reimbursement Request (City of Oakland)

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ESHP Reimbursement Request (City of Oakland)

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The ESHP Reimbursement Request (City of Oakland) form is 2 pages long and contains:

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  • 1 check-box
  • 52 other fields

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File type: PDF

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ESHP Reimbursement Request – Rev 06.11.19
EARTHQUAKE SAFE HOMES PROGRAM (ESHP)
Reimbursement Request
Complete and submit this form via mail or email to request reimbursement for eligible ESHP expenses once your permit
is final. Refer to the maximum cost and reimbursement rates for design and construction as stated in your bid approvals.
SITE ADDRESS:
PROJECT #
OWNER/APPLICANT:
BUILDING PERMIT #:
DATE OF FINAL PERMIT INSPECTION:
1. Register for Oakland’s iSupplier payment disbursement system.
The propery owner must create an account to receive reimbursement. Where the instructions
refer to “company,” use the owner’s name.
• Follow this link: https://www.oaklandca.gov/services/register-with-isupplier.
• Click “Register Here” and enter owner’s name as Company Name, Tax ID (SSN), Email, First and Last
Name, and Phone Number.
• Click “Submit” and you will get confirmation that it was forwarded for review. Enter the name and
assigned ID: Name Registered: ______________________ Registration ID: _______________
• You will receive an email with instructions to log back in and complete your profile, including adding
your contact information and uploading a completed W9 form, which you can find here:
https://www.irs.gov/pub/irs-pdf/fw9.pdf. Note that this system is typically used to pay companies with
contracts with the City, not individual users, so many fields in the profile will not apply to you.
2. Design Costs: include all invoices issued and paid for reimbursable design services.
Invoices must be from entities whose bids were submitted and approved by ESHP and the amounts
must not total more than the approved bid(s).
$
DESCRIPTION
CHECK#/PAYMENT ID
AMOUNT PAID
$
DESCRIPTION
CHECK#/PAYMENT ID
AMOUNT PAID
$
DESCRIPTION
CHECK#/PAYMENT ID
AMOUNT PAID
Total for Design Services:
$
3. Permit Fees Paid by Owner: provide proof of payment for permit fees if eligible for reimbursement.
Reduced fee permits issued for $250 are not eligible for reimbursement. If permit fees were paid by
the design or construction firm, include that invoice in the appropriate section and leave and this blank.
Paid by Design/Construction
Firm
Permit Fees Paid Directly by Owner:
$
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
RESIDENTIAL LENDING AND REHABILITATION SERVICES
250 FRANK H. OGAWA PLAZA, SUITE 5313
OAKLAND, CALIFORNIA 94612-2034
ResidentialLending@oaklandca.gov
ESHP Reimbursement Request – Rev 06.11.19
4. Construction Costs: include all invoices issued and paid for reimbursable construction services.
Invoices must be from entities whose bids were submitted and approved by ESHP and the amounts
must not total more than the approved bid(s). The final permit valuation must be greater than or equal
to the amount invoiced for construction services before reimbursement can occur.
$
DESCRIPTION
CHECK#/PAYMENT ID
AMOUNT PAID
$
DESCRIPTION
CHECK#/PAYMENT ID
AMOUNT PAID
$
DESCRIPTION
CHECK#/PAYMENT ID
AMOUNT PAID
$
DESCRIPTION
CHECK#/PAYMENT ID
AMOUNT PAID
$
DESCRIPTION
CHECK#/PAYMENT ID
AMOUNT PAID
Total for Construction Services:
$
5. Invoice Summary: Transfer totals from each section above and sum all provided invoices
Design $____________ + Permit $____________ + Construction $____________ = $____________
6. Close-Out Inspection: An ESHP inspection must be conducted after your permit is final and before
reimbursement to confirm that activities were completed as approved by FEMA. This is a separate
inspection from that conducted to final your permit. If you have not already scheduled your close-out
inspection, please indicate your availability:
Preferred Dates:
Preferred Times:
7. Owner Certification
I/we understand or confirm the following:
• This document and the included invoices represent all charges paid for retrofit services approved by
ESHP for which I/we are requesting reimbursement.
• The amount reimbursed will be based on the rate and maximum amount for each type of service as
confirmed at the time of bid approval or as revised and approved by ESHP.
• I declare under the penalty of perjury under the laws of the State of California that the information
provided in this document and as attachments to it are true and correct.
OWNER NAME
SIGNATURE
DATE
OWNER NAME
SIGNATURE
DATE
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ESHP Reimbursement Request (City of Oakland)

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Completed 22 July 2020

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