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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: ❑ This is the final reimbursement <br />request <br />Total Amount Requested: $ <br />(Attach copies of supporting 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 />Name <br />I ltle <br />Mailin AAddress <br />City, State, Zip Code <br />(Please sign in blue ink.) <br />Approved for <br />Phone <br />b-Mall Address <br />rax tvumner <br />Request Tracking Number: Account #: <br />Granroject: t: PSIC Grant Year: PSolution <br />Area <br />Special Instructions / <br />Comments <br />25 <br />