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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 />request <br />❑ This is the final reimbursement <br />[] FYO7 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 />Agency / City Requesting <br />Reimbursement <br />Total Amount Requested: <br />(Attach copies of su ortin invoices) <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 and/or services have been received in full. <br />Authorized Agent <br />Printed Name <br />Title <br />v�DD M&IA) ZZeL <br />Mailing Address <br />-/-)A*7D--) BL-y+t'LJ �� 9 z6 LAP <br />::2 <br />ity, State, zip code <br />ignature <br />(Please sign in blue ink.) <br />7--/4 5-3 L - s�o <br />Phone Number <br />d o /so 0 Q S t.-rf-C!,' 1V -- <br />E-Mail Address <br />2/`/-3%— <br />Fax Number <br />Date <br />Approved for <br />Processing: Date: <br />Request Tracking Number: Account #: <br />Grant: PSIC Grant Year: Project: Solution <br />Area <br />Special Instructions / <br />Comments <br />25 <br />