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Anaheim/Santa Ana Urban Areas Security Initiative <br />Reimbursement Request for Grant Expenditures <br />Mail Reimbursement Request to: <br />❑ This is the final reimbursement request <br />❑ FY06 UASI FY07 UASI <br />Anaheim Police Department Santa Ana Police Department <br />East Station — Homeland Security Bureau Attn: Sgt. Enrique Esparza, Grant Coordinator <br />Attn: Lisa Navarro, Grant Coordinator 60 Civic Center Plaza <br />425 S. Harbor Blvd. P.O. Box 1981 <br />Anaheim, CA 92805 Santa Ana, CA 92702 <br />I Agency / City Requesting Reimbursement I I <br />Total Amount Requested: $ <br />(Attach copies of supporting invoices) <br />Under penalty of perjury, I certify that: <br />• This claim is in all respects true, correct, and all expenditures were made in <br />accordance with applicable laws, rules, regulations and grant conditions and <br />assurances. <br />• All attached invoices for items and/or services have been received in full. <br />Printed Name <br />INW--4 <br />Mailing Address <br />City, State, Zip Code <br />Authorized Agent <br />e Number <br />E-Mail Address <br />Fax Number <br />Signature Date <br />(Please sign in blue ink.) <br />For Anaheim/Santa Ana UASI Grant Coordinator Use Only <br />Approved for <br />Processing: <br />Date: <br />Request Tracking Number: <br />Account #: <br />Grant: <br />UASI <br />Grant <br />project: <br />Solution <br />Year: <br />Area: <br />Special Instructions / <br />Comments <br />42 <br />