HomeMy WebLinkAboutSubgrant Forms & ReqmtsSTATE OF FLORIDA
DIVISION OF EMERGENCY MANAGEMENT
SUBGRANT FORMS and REQUIREMENTS
Quarterly Financial History Report/ Status Report (Form 1 and Form 2):
1. These reports must be completed in full on a quarterly basis. These are required reports and must be submitted no
later than 30 days after the end of each period of the program year in order to be considered in compliance with the
terms of the contract.
2. These reports are to include, but not be limited to, the work that has been completed, the work in progress and the timeline
of the work left to be completed. If any delays from the original timeline have occurred, specify the reason and revise the
completion timeline.
3. If expenditures do not occur during the time frame given, a complete explanation should be given on Form 1 and 2.
Reimbursement Request (Form 3) and Detail of Claims (Form 4):
1. These forms are to be filed as needed. Complete Reimbursement Request by entering all information needed for
reimbursement.
2. The Detail of Claims form must accompany the Reimbursement Request form, along with the Budget detail Worksheet.
3. The Reimbursement Request form must be signed by the contract manager or someone with equal authority.
4. Claims are to be submitted to the following address:
DIVISION OF EMERGENCY MANAGEMENT
FINANCE AND ADMINISTRATION
DHS GRANTS UNIT
Attn: (Grant Manager's name)
2555 SHUMARD OAK BOUEVARD
TALLAHASSEE, FLORIDA 32399-2100
Close Out Report- (Form 5):
1. Close Out Reports are due as soon as the final payment has been made and all final expenditures have occurred.
2. The agreement cannot be considered closed until the Close Out Report has been received.
Documentation of project expenditures:
1. Grantees must maintain documentation of expenditures for a minimum period of five years following the close of
project/program operations unless audits require a longer period of time.
2. Grantees should maintain a financial file with copies of back-up documentation for all paid project/program expenditures
made by the grantee during the grant period. Documentation of expenditures against the program will be reviewed and
verified during on -site monitoring visits or when necessary by the DEM staff. Acceptable documentation Includes copies of
purchase orders and paid vouchers, paid invoices or cancelled checks, payroll vouchers, journal transfers, etc. These
documents should be submitted when requesting reimbursement.
3, In order to document hours worked on the program by permanent or temporary staff, the grantee may use its own time and
attendance forms.
4. All claims for reimbursement of expenditures must be submitted on the approved DCA financial reporting forms. Claims
not submitted on the proper form cannot be processed and will be returned for corrections.
IF YOU WISH TO OBTAIN THESE FORMS ELECTRONICALLY, PLEASE NOTIFY YOUR CONTRACT MANAGER
UASI Report Forms - 2010.xlsm/Instructions, Forms 1, 2 & 3 1 of 14
GRANTEE:
AGREEMENT #
DIVISION OF.EMERGENCY MANAGEMENT
FINANCIAL HISTORY REPORT/QUARTERLY STATUS. REPORT
FORM 1 AND 2
(Select Me quarter of submission along with year)
QUARTERLY REPORTING DUE DATES
JANUARY 1 - MARCH 31 - Due no later than April 30,
APRIL 1 - JUNE 30 - Due no later than July 31,
JULY 1 - SEPTEMBER 30- Due no later Oran October 31,
NA
NA
NA
!` OCTOBER 1 - DECEMBER 31 - Due no tater than January 31, NA
FINANCIAL'. HISTORY REPORT
THIS IS A REQUIRED DQCUMENT.AND MUST BE SUBMITTED QUARTERLY,
CUMULATIVE
TOTAL
ALLOCATED
QUARTERLY
FUNDS EXPENDED
CUM. FUNDS
EXPENDED
REMAINING
BALANCE
1. Planning Costs
$0.00
$0.00
$0.00
$0.00
2. Training Costs
$0.00
$0.00
$0.00
$0.00
3. Exercise Costs
$0.00
$0.00
$0.00
$0.00
4. Organizational Costs
$0.00
$0.00
$0.00
$0.00
5. Equipment Costs
$0.00
$0.00
$0.00
$0.00
6. Manament and Administration
Costs (limited to 3% of the total
award)
$0.00
$0.00
$0.00
$0.00
TOTAL EXPENDITURES
$0.00
$0.00
$0.00
$0.00
TOTAL PAYMENTS PREVIOUSLY RECEIVED
I hereby certify that the above costs are true and valid costs incurred in accordance with the project agreement.
Signed:
Contract Manager or Financial Officer
QUARTERLY; STATUS REPORT
THIS IS AREQUIRED DOCUMENT AND MUST BE SUBMITTED SEMI ANNUALLY;
This information must be clearly linked to the project TIMELINE, DELIVERABLES AND THE SCOPE OF WORK.
Report events, progress, delays, etc. that pertain to this project.
(Attach additional page(s) if needed.)
TO BE COMPLETED BY FDEM STAFF
DATE SUBMITTED TO FDEM
UASI Report Forms - 2010.xlsm/Instructions, Forms 1, 2 & 3
2 of 14
UASI Report Forms - 2010.xlsm/Instructions, Forms 1, 2 & 3 3 of 14
DIVISION OF EMERGENCY MANAGEMENT
REIMBURSEMENT REQUEST
FORM 3'°
Grantee
Payment Date
Address
Agreement #
Payment #
Phone #
Amount
COSTS INCURRED DURING THE PERIOD OF: through
THIS MUST BE ACCOMPANIED' BY THE DETAIL OF CLAIMS FORM
1. Planning Expenditures
2. Training Expenditures
3. Exercise Expenditures
4. Organizational Exenditures
5. Equipment Expenditures
Management and Administration Expenditures
6. (limited to 3% of the total award)
$
TOTAL EXPENDITURES $
I hereby certify that the above costs are true and valid costs incurred in accordance with the project agreement.
Signed:
Contract Manager or Financial Officer
TO BE COMPLETED BY DEM STAFF
AGREEMENT AMOUNT $0.00
PREVIOUS PAYMENT(S) $0.00
THIS PAYMENT $0.00
REMAINING BALANCE $0.00
TOTAL AMOUNT TO BE PAID
ON THIS INVOICE
$0.00
DATE SUBMITTED TO FDEM
UASI Report Forms - 2010.xlsm/Instructions, Forms 1, 2 & 3
4 of 14
IWISION OF EMERGENCY MANAGEMEK
RMf4
PLEASE SUBMIT A SEPARATE FORM (4) FOR EACH OF THE FOLLOWING CATEGORIES
1 PlanningExpenddures.
2 Trammg Expenditures
3 Exercise Expenditures
4 Organ.zational Expenditures
5 Equipment Expenditures
6 Management and Administration Expenditure
(limited to 3 / of the total award)
GRANTEE:
COST INCURRED DURING THE PERIOD OF:
4
CATEGORY
Planning
1
AGREEMENT #
VENDOR
DATE PAID
CHECK #
DESCRIPTION
AMOUNT
(Requested for reimbursement)
TOTAL EXPENDITURES
$0.00
1. FORM MUST BE COMPILED FROM FORM 4B BY CATEGORY
2. FORM MUST ACCOMPANY THE REIMBURSEMENT REQUEST
DIVISION OF EMERGENCY MANAGEMENT
DETAIL OF CLAIMS
FORM 4A
THIS FORM IS BACKUP AND MUST ACCOMPANY THE REIMBURSEMENT REQUEST AND
DETAIL OF CLAIMS, FORM 46
The Recipient is required to provide a completed budget detail worksheet, to the Division, which accounts for the total award for
issue 08 as described in the "Proposed Program Budget".
If any changes need to be made to the "Budget Detail Worksheet", after the execution of this contract, contact the contract
manager listed in this contract via email or letter.
k,,, "Ci, "a,
' i.1 �{
.j ine;;Itemg
tr�aY' ''�,'C'� W.'R ��5.7 L/. �'ess ty ��'* �..`.�v .t' ` ± IL'0'
'' jl $ �. J ._ t r� l .f �'. ai Y15' Yt yi+3.F '}„ y
'' ,,g 9AI(owabte PJanntng Cosfs ,,.
�i, i' �P:� ,
/ 6'.. -Y'4k'f�
t,Quantlty.
i r w...S � �i,,,
'�%'yr R �,i Yi M3^ 33 Yi vnaciln
5"pUnit Costs =7;
•"T ,,, P��.,1°v=o a'f miff;
t .� YJ.�
Tofal Cost ",..
I3 Jam , i7
.:rlb } 1�#;
xr _'�#;.,
Developing hazard/threat-specific annexes that Incorporate
the range of prevention, protection, response, and recovery
activities
$0.00
Developing and implementing homeland security support
programs and adopting ongoing DHS national initiatives
$0.00
Developing related terrorism prevention activities
$0.00
Developing and enhancing plans and protocols
$0.00
Developing or conducting assessments
$0.00
Hiring of full or part-time staff or contractors/consultants to
assist with planning activities (not for the purpose of hiring
public safety personnel fulfilling traditional public safety duties)
$0.00
Conferences to facilitate planning activities
$0.00
Materials required to conduct planning activities
$0.00
Travel/per diem related to planning activities
$0.00
Overtime and backfill costs - Payment of overtime expenses
will be for work performed by award (SAA) or sub -award
employees in excess of the established work week (usually 40
hours) related to the planning activities for the development
and implementation of the programs under HSGP.
Other projects areas with prior approval from FEMA
$0.00
SUBTOTAL
$o.00
>3 Ar
Lt a
rne Item.
fl1 owable FiSGP and LIc rP car anizattonaf
- ` <x �Cosfs x f 9 �f
t�_F,,.., ._.. � �__ . �.� �.,�. ��. �.tisk .....�.,,
��f �
Quantlt
f....- F..Y
w"
,k 'Urrrt Cosh 3 `
�
� �..,,.,. ..
al�Cos>, ; ,
_... _. ���,__._����,
' * ' � y,
fa
Overtime for information, investigative, and intelligence
sharing activities (up to 50 percent of the allocation)
$0.00
Reimbursement of select operational expenses associated
with increased security measures at critical infrastructure
sites, incurred during time periods of DHS-declared alerts (up
to 50 percent of the allocation).
$0.00
Hiring of new staff position/ contractors/consultants for
participation in information/intelligence analysis and sharing
groups or fusion center activities (up to 50 percent of the
allocation)
$0.00
SUB TOTAL
$o.00
6 of14
DIVISION OF EMERGENCY MANAGEMENT
DETAIL OF CLAIMS
FORM 4A
oF{� fjy, ts.}
'�s , h' ,�''
rl t.itle ef►1',
f fT .Nf f +d , i d vv U
z ti ,f rl `� ' ."�k � ,"•::w J, `�'•m,I,,, kY kt .
,k., h a 3k ,AIlow:a,bte Tralntng Cost Yam''''
r'�rb k M1'i Rv
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Quan,ttfy
f ,� x�<:x "r 4 r
�'�'ta t v ,., rt ? �
; Unit+Cpst,,r ,.,,
r.2'�'tf<.: x �'f41yQ.?�
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;R: ,Tatal;:Ggst,
Y PTA
; 7
S
Overtime and backfill for emergency preparedness and
response personnel attending FEMA-sponsored and approved
training classes.
$0.00
Overtime and backlit! expenses for part-time and volunteer
emergency response personnel participating in FEMA training.
$0.00
Training, Workshops and Conferences - Grant funds may
be used to plan and conduct training workshops or
conferences to include costs related to planning, meeting
space and other meeting costs, facilitation costs, materials
and supplies, travel and training plan development.
$0.00
Full or Part -Time Staff or Contractors/Consultants - Full or
part-time staff may be hired to support training -related
activities. Payment of salaries and fringe benefits must be in
accordance with the policies of the state or local unit(s) of
government and have the approval of the state or the
awarding agency, whichever is applicable. The services of
contractors/consultants may also be procured by the state in
the design, development, conduct, and evaluation of CBRNE
training. The applicant's formal written procurement policy or
the Federal Acquisition Regulations (FAR) must be followed.
•
$0.00
Travel - Travel costs (i.e., airfare, mileage, per diem, hotel,
etc.) are allowable as expenses by employees who are on
travel status for official business related to the planning and
conduct of the training project(s) or for attending ODP-
sponsored courses. These costs must be in accordance with
state law as highlighted in the OJP Financial Guide. States
must also follow state regulations regarding travel. If a state
nr farritnn, dnac nnl haun a Iraval nnliru tha,, m, ,cl fnlln..,
•
$0.00
Supplies - Supplies are items that are expended or consumed
during the course of the planning and conduct of the training
project(s) (e.g., copying paper, gloves, tape, and non -sterile
masks.) .
$0.00
Tuition for higher education
$0.00
Other Items - These costs include the rental of
space/locations for planning and conducting training, badges,
etc. -
$0.00
SUB TOTAL
$0.00
A complete list of ODP approved training courses may be found at
www.olp.usdol.poviodp/docs/Eliqible Federal Courses.pdf
4 rf
Line Item
i + '- �.- }.:.. 'h i 7 X 3'Y
.. A. r �y, A. f CC . $' 1 !ice { % F (
. _ ;AIIo able Exercise Costs " r,
�" f.i. Y5 .�'SR
! f 1Fah.
„Quantity
tN 'vi ? k S- 3 tk
"; Yir;' ` S ..
, ; fi -Un taCost 4_
3 k T: k�'�d.: A
Y 1i `a T f Fs, {.
;' x ` Total. COst
��'Y
Design, Develop, Conduct and Evaluate an Exercise
$0.00
Exercise Planning Workshop - Grant funds may be used to
plan and conduct an Exercise Planning Workshop to include
costs related to planning, meeting space and other meeting
costs, facilitation costs, materials and supplies, travel and
exercise plan development.
$0.00
7 of14
DIVISION OF EMERGENCY MANAGEMENT
DETAIL OF CLAIMS
FORM 4A
Full or Part -Time Staff or Contractors/Consultants - Full or
part -lime staff may be hired to support exercise -related
activities, Payment of salaries and fringe benefits must be in
accordance with the policies of the state or local unit(s) of
government and have the approval of the stale or the
awarding agency, whichever is applicable. The services of
contractors/consullants may also be procured to support the
design, development, conduct and evaluation of CBRNE
exercises. The applicant's formal written procurement policy or
the Federal Acquisition Regulations (FAR) must be followed.
$0.00
Overtime and backfill costs —Overtime and backfill costs,
including expenses for part-time and volunteer emergency
response personnel participating in FEMA exercises
$0.00
.
Implementation of HSEEP
$0.00
Travel - Travel costs (i.e., airfare, mileage, per diem, hotel,
etc.) are allowable as expenses by employees who are on
travel status for official business related to the planning and
conduct of the exercise project(s). These costs must be in
accordance with state law as highlighted in the OJP Financial
Guide. States must also follow state regulations regarding
travel. If a slate or territory does not have a travel policy they
must follow federal guidelines and rates, as explained in the
OJP Financial Guide. For further information on federal law
pertaining to travel costs please refer to
http://www.ojp.usdoj.gov/FinGuide.
$0.00
Supplies - Supplies are items that are expended or consumed
during the course of the planning and conduct of the exercise
project(s) (e.g., copying paper, gloves, tape, non -sterile
masks, and disposable protective equipment).
$0,00
Other Items - These costs include the rental of.
space/locations for exercise planning and conduct, exercise
signs, badges, etc.
$0.00
SUB TOTAL
$o.00
'�..,"`+s32'r-3
�T 'ALa
Lme Item_
.•sv r �'�v; :.f�Y 3 :f.,_,yx ` �t,.
{� P t ,eZx,l.�. �' r9 n P ,g
�� Atlowa;ble E,gutpment Costs = E v;_s ,n,
syV`r- �,
Qt�lantttyF
}.. 5 •,.y.e. s t x'y, 4r
yr j? ; �
Umf Cos(
.0 ,,s^,��`",."r �3j.+
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The table below highlights the allowable equipment categoes
allowable equipment categones, and specific equipment
based Authorized Equipment List at http /Iwww.rkb us
* Ciick`on Authorized Equipment List (AEL)
* If you wish to purchase a piece of•equipment from ny a
category put;the AEL item number' and title
n for this
eligible under
categorybelow
award A comprehensive
each category can` be
then in the space
listing of these
found on the web
given below that
Personal Protective Equipment
$0.00
$0.00
Explosive Device Mitigation and Remediation Equipment
$0.00
$0.00
CBRNE Operational Search and Rescue Equipment
$0.00
$0.00
Information Technology
$0.00
8 of14
DIVISION OF EMERGENCY MANAGEMENT
DETAIL OF CLAIMS
FORM 4A
$0.00
Cyber Security Enhancement Equipment
$0.00
$0.00
Interoperable Communications Equipment
$0.00
$0.00
Detection Equipment
$0.00
$0.00
Decontamination Equipment
$0.00
$0.00
Medical
$0.00
$0.00
Power
$0.00
$0.00
CBRNE Reference Materials
$0.00
$0.00
CBRNE Incident Response Vehicles
$0.00
$0.00
Terrorism Incident Prevention Equipment
$0.00
$0.00
Physical Security Enhancement Equipment
$0.00
$0.00
Inspection and Screening Systems
$0.00
$0.00
Agriculture Terrorism Prevention, Response, and Mitigation
Equipment
$0.00
$0.00
CBRNE Prevention and Response Watercraft
$0.00
$0.00
CBRNE Aviation Equipment
$0.00
$0.00
CBRNE Logistical Support Equipment
$0.00
$0.00
Intervention Equipment
$0.00
$0.00
Other Authorized Equipment (include any construction or
renovation costs in this category; Written approval must be
provided by FEMA prior to the use of any funds for
construction or renovation)
$0.00
$0.00
SUB TOTAL
$0.00
9 of14
DIVISION OF EMERGENCY MANAGEMENT
DETAIL OF CLAIMS
FORM 4A
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< f�yt�
Line 9:.ry
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C�.yA' . . }lriy, ';;.„. `.`.]t 4-.F`...�:1.. . J •t�'+7. 'hf's l �Y_i 4 ,t, ;.'
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Up to 50 percent of total program funds may be used for
personnel and personnel -related activities
.$0.00
SUB TOTAL
$o.00
i.P
a �T:.
. f ti \s�. P';
= ,
Fa •?-
,
L-;' -,, .A
Line fterrt
E� !
r �g ble ManagemenandAdrninistratlor�
i, i_z«d>& .V� .ia+..P ,' rf,ts.em tire, jY3 c v. iu'� ..IsAW+;. {i r9 .,r
:,.Costs (trtanagemdfi i d admfntstration co s
a.4.0r ,... ?is.. #.: Q _„,.- _ t ., :Yto�S"+c t r'Sil'i t Y,.-
mayxnotrexceed=3 //orof the Recipient sttotai
Pn L, aw.gr� '�' •1*f z," lfi. @kt Xf'x.!tx�c�`". :_ 4' �h 4 V "e.'' y� �y-n ._^
b;f� *i .t“'" j �' award) >;< .s
a t *
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• l'�5 i '=
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Quantity>
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y3 ��$r�.
t M1KBL SF� �. L9�`S
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Hiring of full-time or part-time staff or contractors/consultants:
• To assist with the management of the FY 2010 UASI
• To assist with application requirements and the
implementation of the FY 2010 UASI
• To assist with the compliancy with reporting and data
collection as it may relate to the FY 2010 UASI
• Meeting compliance with reporting/data collection
requirements, including data calls.
$0.00
Development of operating plans for information collection and
processing necessary to respond to DHS/FEMA data calls.
$0.00
Overtime and backfill costs — Overtime expenses are defined
as the result of personnel who worked over and above their
normal scheduled daily or weekly worked time in the
performance of FEMA — approved activities. Backfill Costs
also called "Overtime as Backfill" are defined as expenses
from the result of personnel who are working overtime in order
to perform the duties of other personnel who are temporarily '
assigned to FEMA — approved activities outside their core
responsibilities. Neither overtime nor backfill expenses are the
result of an increase of Full — Time Equivalent (FTEs)
employees. These costs are allowed only to the extent the
payment for such services is in accordance with the policies of
the state or unit(s) of local govemment and has the approval
of the state or the awarding agency, whichever is applicable.
In no case is dual compensation allowable. That is, an
employee of a unit of government may not receive
compensation from their unit or agency of government AND
from an award for a single period of time (e.g., 1:00 pm to 5:00
pm), even though such work may benefit both activities.
Fringe benefits on overtime hours are limited to Federal
Insurance Contributions Act (FICA), Workers' Compensation
and Unemployment Compensation.
$0.00
Travel expenses
$0.00
Meeting -related expenses (For a complete list of allowable
meeting -related expenses, please review the OJP Financial
Guide at http://www.ojp.usdoj.gov/FinGuide).
. $0.00
computers,
other
the
Acquisition of authorized office equipment, including personal
laptop computers, printers, LCD projectors, and
equipment or software which may be required to support
implementation of the homeland security strategy.
$0.00
10 of14
DIVISION OF EMERGENCY MANAGEMENT
DETAIL OF CLAIMS
FORM 4A
The following are allowable only within the contract period:
• Recurring fees/charges associated with certain equipment,
such as cell phones, faxes, etc.
• Leasing and/or renting of space for newly hired personnel to
administer programs within FY10 UASI.
$0.00
SUB TOTAL
$o.00
i'.7+r'ahy6
°y`hxY�h iIY*
h % . 1 i ti sPrr'r '-,
NA,L
�R. $�
` .
DU�E'u7sS S.
$0.00
11 of14
DIVISION OF EMERGENCY MANAGEMENT
PROJECT MILESTONES AND DELIVERABLES.
FO
RM 4C'
THIS IS A REQUIRED DOCUMENT AND MUST BE SUBMITTED WITH EACH REQUEST FOR REIMBURSEMENT
If applicable, please
select the procurement
method(s) associated
with this request.
Method of
Procurement:
ITB
r
RFP
ITN
r
Single/Sole Source
(Cost Analysis)
Emergency
Certification
Other:
Specify
N/A
r
Categories
Funds Expended (This Request)
1. Planning Costs
2. Training Costs
3. Exercise Costs
4. Organization Costs
5. Equipment Costs
6. Management and Administration Costs
(limited to 3% of the total award)
TOTALS
$0.00
Deliverables should be
*Directly related to *Used to measure *Specific, Quantifiable, Measureable *Events that *A necessary part of
the scope progress & Verifiable trigger
payment
your performance
NARRATIVE SUMMARY OF EXPENDITU
DRES
eliverabies'.:lncluding Minimum Perfvormance" Standards<
his information must beclea ly linked to the'` project TIMELINE, DELIVERABLES AND SCOPE OF WOR
AGENCY MANAGEMENT CERTIFICATION:;
I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms
and conditions of the executed agreement on file. I understand that the FDEM reserves the right to require additional
documentation and/or conduct periodic post -audits of any agreement.
Management Name Printed Management Signature
Date:
DIVISION OF. EMERGENCY•MANAGE;
2555 SHUMARD OAK.BOULEVAMENTRD
TAHASSEE, FLORRIA:3239,9 2100
LLA
' :
CLOSE OUT
M REPORT
FOR5
This form should be completed and submitted to the Division no
later than sixty (60) days after the termination date of the Agreement
GRANTEE
ADDRESS
CITY AND STATE
EXPENDITURES,
1. Planning Costs
2. Training Costs
3. Exercise Costs
4. Organization Costs
5. Equipment Acquisition Costs
6. Management and Administration Costs
TOTAL EXPENDITURES
$0.00
Total funds received from the Division of
Emergency Management under this
Agreement (Column 4, Line 7)
Less total grant award expenditures
(Column 2, Line 7)
Equals balance of Agreement owed to
DEM
$0.00
AGREEMENT #
AGREEMENT AMOUNT
AGREEMENT PERIOD
TOTAL
$0.00
$0.00 . Agreement Amout . $0.00
$0.00
Refund due to State? Yes ; No
If Yes, refund check enclosed?
If No, enter date refund will be submitted
Yes No
Refund and/or final interest check are due no later than ninety (90)
days after the expiration date of the Agreement.
Make check payable to : Cashier,
Department of Community Affairs
Less total funds received
under this Agreement
(Column 4, Line 7)
$0.00
Balance of Agreement $0.00
I hereby certifiy that the above costs are true and valid costs
incurred In accordance with the project Agreement, and that the
matching funds, In -kind or cash, were utilized toward the project
in this Agreement.
Signed:
Date:
Mail to: Division of Emergency Management, 2555 Shumard Oaks Boulevard, Tallahassee, FL 32399-2100