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<br />Attachment A <br /> <br />Urban Areas Security Initiative <br />Reimbursement Request for Grant Expenditures <br /> <br />Award # <br /> <br />Mail Reimbursement ReQuest to: <br /> <br />Applicant: <br /> <br />Core City / Transit Agency <br /> <br />Governor's Office of Emergency Services <br />Grant Payments Unit <br />Post Office Box 419023 <br />Rancho Cordova, CA 95741-9023 <br /> <br />OES ill #: <br /> <br />Please mark this box to indicate a change in <br />the Authorized Agent Mailing Address <br />belowD <br /> <br /> Total <br /> Expenditures <br />Project # Solution Area Expenditure Period (from/to dates) for the <br /> Expenditure <br /> Period <br />, <br /> Grand Total <br /> <br />Under penalty of per jury, I certify that: <br /> <br />· I am the duly authorized officer of the claimant herein. <br />· This claim is in all respects true, correct, and all expenditures were made in accordance with <br />applicable laws, rules, regulations and grant conditions and assurances. <br /> <br />Authorized Agent (per Governing Body Resolution) <br /> <br />Printed Name <br /> <br />Phone Number <br /> <br />Title <br /> <br />E-Mail Address <br /> <br />Mailing Address <br /> <br />Fax No. <br /> <br />City, State, Zip Code <br /> <br />Date <br /> <br />Signature <br /> <br />FY04 Urban Areas Security Initiative <br /> <br />Page 78 <br />