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<br />Santa Ana Urban Areas Security Initiative/ <br />Public Safety Interoperable Communications Grant <br />Reimbursement Request for Grant Expenditures <br /> <br />Mail Reimbursement Request to: <br /> <br />o This is the final reimbursement request <br /> <br />o FY07 PSIC <br /> <br />Santa Ana Police Department <br />Altn: Sgt. Enrique Esparza, Grant Coordinator <br />60 Civic Center Plaza <br />P.O. Box 1981 <br />Santa Ana, CA 92702 <br /> <br /> <br />Agency I City Requesting Reimbursement <br /> <br />$ <br /> <br />Under penalty of perjury, I certify that: <br />. I 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 andlor services have been received in full. <br /> <br />. <br /> <br />Authorized Agent <br /> <br />Phone Number <br /> <br />Printed Name <br /> <br />E-Mail Address <br /> <br />Title <br /> <br />Fax Number <br /> <br />Mailing Address <br /> <br />City, Stale, Zip Code <br /> <br />Date <br /> <br />Signature <br />(Please sign in blue ink.) <br /> <br />For Santa Ana UASIIPSIC Grant Coordinator Use Onlv <br />Approved for \ Date:T <br />Processinl!: <br />Request Tracking Number: Account #: <br />Grant: I PSIC I Grant I Project: l Solution <br />Year: Area: <br />Special Instructions I I <br />Comments <br /> <br />37 <br />