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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: 0 This is the final reimbursement <br />request <br />Agency / City Requesting <br />Reimbursement <br />Total Amount Requested: Ts - <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 />Printed Name Phone Number <br />Title E-Mail Address <br />Mailing <br />City, State, Zip Code <br />(Please sign in blue ink.) <br />Fax Number <br />t {� y� <br />4 "..i.�ll Ax,.... <br />Approved for <br />a"{ <br />Processing: <br />Date: <br />Request Tracking Number: <br />Account #: <br />Grant: <br />PSIC <br />Grant Year: <br />Project: <br />Solution <br />Area <br />Special Instructions / <br />Comments <br />25 <br />