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FY08 Emergency Management Performance Grant Exh~R~OfS491f~ Request Reimbursement Request Award # 2008-GR-XXX Mail Reimbursement Request to vour Re Tonal Once Subgantee oES ID #: X00-00000 Office of Emergency Services Office of Emergency Services Office of Emergency Services Coastal Region Inland Region Southern Region 1300 Clay Street, Suite 400 3650 Schriever Avenue 4671 Liberty Avenue Oakland, CA 946]2 Mather, CA 95655 Los Alamitos, CA 90720 1. Reimbursement Request for which state fiscal year? (Cbeckonlyone/iscatyearboxperBermbursenenrrequest) Check the Final Reimbursement Request box if this is your final request: ® 10/01/07 to 6!30/08 2 Federal Funds Expended (A3 = A I + A2) ^ 07/01/08 to 06/30/09 Local Subgrant Match Expended (B3 = B I + g2) Total Subgrant Expenditures (C=A3+B3) 3 Total Emergency Program Expenditures [C r Additional Local Expenditures (if applicable)] ^ Fiual Reimbursement Request Cumulative Previously Requested Amount Ar $0.00 Current Requested Amount A2 $22,278 el s: $0.00 $22,278 = Cumulative Amount to Date ~ $22,278 t $22,278 c $44,556 $48,556 Under penalty of perjury, I certify that: ^ 1 am the duly Authorized Agent of the claimant herein. ^ This reimbursement request is in all respects true, correct, and in accordance with applicable laws, rules, regulations, subgrant conditions and assurances. • All funds requested as a reimbursement have been matched with local funds. • Emergency Program Expenditures may not be used for any other match. Authorized Ageut (Per Governing Body Resolution/State Agency Signature Authority Form) John Adams (000) 000-00000 Printed Name Phone No. CAO/Director of OES iala~narniaoes.EOv Tttle E-Mail Address 1234 13roadwav Street Mailing Address Anytown, CA 91191 City, State, Zip Code Joiwt.At- Signature (0001000-0000 Fax No. 7/10/08 Date ^ Check this box if this is a new address for the Authorized Agent. Page 74 of 80 FY08 EMPG Recipient Subgrant Guide for Local Government 56