Laserfiche WebLink
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 />FY10 UASI Grant Program <br />Sgt. Enrique Esparza, Grant Coordinator Cindy Nickel, Grant Fiscal Coordinator <br />Santa Ana Police Department Anaheim Police Department <br />Homeland Security Division East Station-Homeland Security Bureau <br />60 Civic Center Plaza-P.O. Box 1981 425 S. Harbor Boulevard <br />Santa Ana, CA 92702 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 />Authorized Agent <br />Printed Name Phone Number <br />Title <br />Mailing Address <br />City, State, Zip Code <br />Signature (Please sign in blue ink) <br />_L_ /r_ ._ <br />E-Mail Address <br />Fax Number <br />Date <br />X41 f111a11e1rnJSanLa Ana UHJI GraHL IUUrUIndtUr USE' Urlly <br />Approved for Processing Date <br />Account and Activity Number <br />Grant Year/Grant Project and Solution Area <br />Special Instructions/Comments <br />38