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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: ~ This is the final reimbursement request. <br />FY09`UASI Grant Program <br />F i <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 />FY10 UASI Grant Program <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, <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 />Authoriied,Agent _ <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 Anaheim/Santa Ana UASI' Grant.Coordinatar Use'Only <br />Date <br />Account and A <br />Number <br />Grant Year/Grant Project and Solution Area <br />Instructions/Comments <br />38 <br />