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FY 06 Emergency Management Performance Grant (EMPG) <br />Payment Request for Grant Expenditures <br />Award # <br />Mail Reimbursement Reguest to your Regional Office: Subgrantee:_ <br />Governor's Office of Emergency Services OES ID #: <br />Coastal Region Inland Region Southern Region <br />1300 Clay Street, Suite 408 3650 Schriever Avenue 4671 Liberty Avenue <br />Oakland, CA 94612 Mather, CA 95655 Los Alamitos, CA 90720 <br />Payment Request for which time period? (Check only one box per Payment request): <br />❑ 10101105 to 06/30/06 ❑ 07/01/06 to 09/30/06 <br />Project # <br />Federal Funds Requested for <br />the time period checked <br />above <br />Total Funds Expended to <br />Date <br />Total <br />Under penalty of perjury, I certify that: <br />• I am the duly Authorized Agent of the claimant herein. <br />• This payment request is in all respects true, correct, and in accordance with applicable <br />laws, rules, regulations, grant conditions and assurances. <br />• All funds requested as an advance will be expended within 120 days of this request. <br />• All funds requested as a reimbursement have been matched with local funds. <br />Authorized Agent (Per Governing Body Resolution /State Agency Signature Authority Form) <br />Printed Name <br />Address <br />City, State, Zip Code <br />Phone No. <br />E -Mail Address <br />Fax No. <br />Signature Date <br />❑ Check this box if this is a p ®gp ;Jbr the Authorized Agent. <br />