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Attachment D
DIVISION OF EMERGENCY MANAGEMENT
REQUEST FOR ADVANCE OR REIMBURSEMENT OF
HAZARD MITIGATION GRANT PROGRAM FUNDS
RECIPIENT NAME: City of Miami — Department of Fire Rescue
ADDRESS:
CITY, STATE, ZIP CODE:.
PAYMENT No:
FEMA Tracking Numbers: FEMA PDMC-004
DEM Agreement No: 07DM-68-11-23-02 .
Eligible
Amount
100%
Obligated
Federal
75%
Obligated
Non -Federal
25%
Previous
Payments
Current
Request
DEM Use Only
Approved
Comments
TOTAL CURRENT REQUEST $
I certify that to the best of my knowledge and belief the above accounts are correct, and that all disbursements
were made in accordance with all conditions of the DEM agreement and payment is due and has not been
previously requested for these amounts.
RECIPIENT SIGNATURE
NAME AND TITLE DATE:
TO BE COMPLETED BY DIVISION OF EMERGENCY MANAGEMENT
APPROVED PROJECT TOTAL $
ADMINISTRATIVE COST $ GOVERNOR'S AUTHORIZED REPRESENTATIVE
APPROVED FOR PAYMENT $
DATE
30
A
DIVISION OFEMERGENCY MANAGEMENT
SUMMARY OF DOCUMENTATION IN SUPPORT OF AMOUNT
CLAIMED FOR ELIGIBLE DISASTER WORK UNDER THE
HAZARD MITIGATION GRANT PROGRAM
Applicant: City of Miami — Department of Fire Rescue Disaster No.
DEM Agreement No. 07DM-68-11-23-02-
FEMA Tracking # FEMA 2005-004
Applicant's
Reference No.
(Warrant, Voucher,
Claim Check, or
Schedule No.)
Date of delivery
of articles,
completion of
work or
performance
services.
DOCUMENTATION
List Documentation (Applicant's payroll, material out of
applicant's stock, applicant owned equipment and name of
vendor or contractor) by category and line Item in the
approved project application and give a brief description of
the articles or services.
Applicant's
Eligible Costs
100%
TOTAL