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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 /> <br />T <br />E~ U9 U.ASI Grant.Program ' ` <br />a~.. .,, ~ F'~'l0 UASI Grant Program <br /> <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 Cindy Nickel, Grant Fiscal Coordinator <br />Anaheim Police Department <br />East Station-Homeland Security Bureau <br />425 S. Harbor Boulevard <br />Anaheim <br />CA 92805 <br /> , <br /> <br />Agency/ City Requesting Reimbursement <br /> <br />Pa oll Total (Salaries, Overtime, Backfill, etc) <br />Travel Total (Tuition, Meals, Lod in ,etc) <br />E ui ment & Su lies Total <br />Total Amount Re uested _ <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 />Authoried Agent ~~ ~ ~- <br />Printed Name <br />Title <br />Mailing Address <br />City, State, Zip Code <br />Signature (Please sign in blue ink) <br />For Anaheiin/Santa Ana'UASI Grant Coordinator Use Only ~' <br />Account and <br />Grant Year/Grant <br />Number <br />Phone Number <br />E-Mail Address <br />Fax Number <br />Date <br />Date <br />Project and Solution Area <br />Instructions/Comments <br />38 <br />