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FY08 Emergency Management Performance Grant ExhibB'9'BP~A'S~'E'~ Re<1°e`i <br />Reimbursement Request <br />Award # 2008-GR-XXX <br />Mail Reimbursement Request to vour Re>;ional Ofi:ce: Subgrantee <br />OES ID #: 000-00000 <br />Office of Emergency Services Office of Emergency Services Office of Emergency Services <br />Coasta] Region Inland Region Southern Region <br />1300 Clay Street, Suite 400 3650 Schriever Avenue 4671 Liberty Avenue <br />Oakland, CA 94612 Mather, CA 95655 Los Alamitos, CA 90720 <br />1. Reimbursement Request for which state fiscal year? (Check only onefescalyear box per Relnrburstment request) Cheek <br />the Final Reimbursement Request boa if this is your final request: <br />^ 10!01/07 to 6/30108 <br />2 Federal Funds Expended <br />(A3 = A I + A2) <br />® 07101!08 to 06/30!09 ^ Final Reimbursement Request <br />Local Subgrant Match Expended <br />(B3=B1+ffi) <br />Total Subgrant Expenditures <br />(C=A3+s3) <br />3 Total Emergency Program Expenditures <br />[C+Addi[ional Local Expenditures (if applicable)] <br />Cumuiativc Previouglp Cumnt RequeSicd <br />ReQuested Amount <br />Amount <br />e~ .~ <br />$22,278 $30,000 = <br />^i B2 <br />$22,278 $30,000 = <br />Cumulative Amount <br />to Date <br />~ $52,278 <br />t <br />$52,278 <br />c $104,556 <br />$108,556 <br />Under penalty of perjury, I certify that: <br />^ I am the duly Authorized Agent of the claimant herein. <br />This reimbursement request is in all respects true, correct, and in accordance with applicable laws, rules, <br />regulations, Subgrant conditions and assurances. <br />All funds requested as a reimbursement have been matched with local funds. <br />• Emergency Program Expenditures may not be used for any other match. <br />Authorized Agent (Per Governing Body Resolution/State Agency Signature Authority Form) <br />John Adams (000)000-00000 <br />Printed Name Phone No. <br />CAO/Direc[or of OES 'a namiaoes. ov <br />Title E-Mail Address <br />1234 Broadway Street <br />Mailing Address <br />Anytown, CA 91191 <br />City, State, Zip Code <br />TnLi,n,Arl~a.vn.~ _ _ <br />Signature <br />(0001000-0000 <br />Fax No. <br />9/15/OR <br />Date <br />^ Check this box if this is a new address for the Authorized Agent. Page 75 of 80 <br />FY08 PMPG Recipient Subgrant Guide for Local Govemment 57 <br />