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EMS GRANT PROGRAM EXPENDITURE REPORT
Name of Grantee: Grant ID Code:
Time Period Covered: Beginning Date: Ending Date:
Earned Interest: Amount $
; as of
No
Day Month Year
Major Line Items
TOTAL
Approved Budget Expenditure by Major Line item(s)
$
TOTAL BUDGETED EXPENDITURES
$
Actual Expenditure to Date by Major Line item(s)
TOTAL EXPENDITURES
BALANCE Budgeted Less Actual Expenditures
Include with the progress notes an explanation of how project personnel, equipment, and any problems or barriers
may impact on the grant progress.
I certify the above reports are true and correct. Expenditures were made only for items allowed by
the above referenced grant.
Signature of Authorized Official
Date
DR Form 1684A, Rev. June 2002
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