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Santa Ana Urban Areas Security Initiative/ <br />Public Safety Interoperable Communications Grant <br />Reimbursement Request for Grant Expenditures <br />Mail Reimbursement Request to: <br />❑ FY07 PSIC <br />Santa Ana Police Department <br />Attn: Sgt. Enrique Esparza, Grant Coordinator <br />60 Civic Center Plaza <br />P.O. Box 1981 <br />Santa Ana, CA 92702 <br />❑ This is the final reimbursement request <br />Agency / City Requesting Reimbursement I L po",L`s OLsp j I <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 accordance with applicable laws, <br />rules, regulations and grant conditions and assurances. <br />All attached invoices for items and/or services have been received in full. <br />Printed Name <br />Afot it Ava <br />Mailing Address A <br />Pvt�_, r CA /Z�i7D <br />ty, St t Zip o(K <br />Signature <br />(Please sign in blue ink.) <br />Authorized Agent <br />�%I) 5793-0&t.`7 <br />Phone Number <br />9 CAR..-�� Pl-,e°kc,r�'�+t�►- o �L <br />E-Mail Address <br />61,L*) Ta't-3Y51 <br />Fax Number <br />6:1_1/ 11 /0 <br />Date <br />For Santa Ana UASI/PSIC Grant Coordinator Use Only <br />Approved for <br />Processing: <br />Date: <br />Request Tracking Number: <br />Account #: <br />,rant: <br />PSIC <br />Grant <br />1:7PrjectT.oSolution <br />Year•Area: <br />Special Instructions / <br />Comments <br />25 <br />