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f <br />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 0 FY07 VAST <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 />Agency / City Requesting Reimbursement <br />Total Amount Requested: $ <br />(Attach copies of supporting invoices) <br />Under penalty of perjury, I certify that: <br />• 1 am an authorized officer of the claimant herein. <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 M. <br />Printed Name <br />Address <br />City, State, Lip Code <br />sign in blue ink.l <br />Authorized Agent <br />Phone Number <br />E-Mail Address <br />Fax Number <br />For Anaheim/Santa Ana UASI Grant Coordinator Use Only <br />Approved far <br />Date: <br />Processin <br />Request Tracking Number: <br />Account #: <br />Grant: <br />UASIGrant <br />Project: <br />Solution <br />Year: <br />Area: <br />Special Instructions / <br />Comments <br />42 <br />