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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
Final Report (Check one): rjYes No
Major Line Items
Day Month Year
Approved Budget Expenditure by Major Line Item(s)
TOTAL BUDGETED EXPENDITURES
TOTAL
Actual Expenditure to Date by Major Line Item(s)
TOTAL EXPENDITURES
$
$
I 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
DH Form 1684A, Rev. June 2002