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EXHIBIT D <br />Anaheim and Santa Ana Urban Areas Security Initiative <br />Reimbursement Request for Grant Expenditures <br />Mail Reimbursement Request To: <br />This is the final reimbursement request. <br />FYO~"UASI Grant Program'- `' ~ ~ ~!' <br />11x <br />Sgt. Enrique Esparza, Grant Coordinator <br />Santa Ana Police Department <br />Homeland Security Division <br />60 Civic Center Plaza-P.O. Box 1981 <br />Santa Ana, CA 92702 <br />II FY10 UAS ~~"~.Grarlt p <br />" ~~ ~ ~~~ <br />~ <br />~~ '~~ ~ ~ .. <br />' <br />~ <br />+ I <br />. <br />I' f ~ ~ r~ 1'~- r f~~i rl ~ ` I <br />~ ~~ ii . <br />~ <br /> <br />Cindy Nickel, Grant Fiscal Coordinator <br />Anaheim Police Department <br />East Station-Homeland Security Bureau <br />425 S. Harbor Boulevard <br />Anaheim, CA 92805 <br />Agency/ City Requesting Reimbursement <br />Payroll Total (Salaries, Overtime, Backfill, etc) <br />Travel Total (Tuition, Meals, Lodging, etc) <br />Equipment & Supplies Total <br />Total Amount Requested ~ - <br />Under Penalty of perjury, I certify that: <br />I am the duly authorized officer of the claimant herein. This claim is in all respects true, correct, and all <br />expenditures were made in accordance with applicable laws, rules, regulations, and grant conditions and <br />assurances. All attached documents for items and/or services have been received in full. <br />~,~ <br />~;f ._ _. - ':A~I~~grzed Agents ~- - n_. ' . <br />Printed Name <br />Title <br />Mailing Address <br />City, State, Zip Code <br />Phone Number <br />E-Mail Address <br />Fax Number <br />Signature (Please sign in blue ink) Date <br />For And etm/SantaAna'UASI Grant"Coor~Tinaor.U~se Gnlv:~'.~;~ ~{~~~~. sir . , r, <br /> <br />Approved fns ^-ncQssing Date <br />,,:;~ , <br />Account and Activity l~ ~r <br />Grant Year/Grant Project and Solution Area <br /> <br />Special Instructions/Comments <br />38 <br />