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CITY OF LOS ANGELES URBAN AREA SECURITY INITIATIVE GRANT Reimbursement Request Form Return Reimbursement Reauests tQ;. Rachel Tkatch Mayor's Office of Homeland Security and Public Safety 200 N. Spring St., Room #M-175A Los Angeles, CA 90012 Phone: 213.978.0701 Fax: 213,978,0718 rachel. tkatch @Iacitv.ora Core City: Requesting Agency: Reimbursement Period: to UASi FY03 Part 1 0 UASI FY03 Part 2 0 UASI FY04 0 UASI FY05 0 Line: Prepared By: Phone No.: Please mark this box to indicate final request for reimbursement 0 Type of Expenditure Authorized Total Amount Previously Request Current Request E ui ment Exercise Trainin Plannin o erational Activities Mana emen! & Admin Total This reimbursement claim is in all respects true, correct, and all expenditures were made in accordance with applicable laws, rules, regulations, and grant candn/ons and assurances. In addition. this claim is for cost incurred within the Grant Performance Period. Also, al/ supporling documentation related to these expenditures will be retained in accordance with grant guidelines. Authorized Department Approval: Please Remit Payment to: Print Name Name Title Address Signature Dale City State Zip Phone No. (extension) Fax No Reference No E-mail Address To be completed by HSPS Accounting Department DHS/OES Reimbursement Request By Transaction 10- Dale: DHSIOES Reimbursement Received Cash Receipt No_. JV No Transfer to Depart Date ~ JV No