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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: F-1 This is the final reimbursement request. <br />-FY10 UASI Grah Progra FY11 UASI Grant Program <br />Sgt. Darrin Lee, Grant Coordinator Sgt. Enrique Esparza, Grant Coordinator <br />Anaheim Police Department Santa Ana Police Department <br />Emergency Management Bureau Homeland Security Division <br />425 S. Harbor Blvd. 60 Civic Center Plaza-P.O. Box 1981 <br />Anaheim, CA 92805 Santa Ana, CA 92702 <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 <br />Title <br />Mailing Address <br />City, State, Zip Code <br />Signature (Please sign in blue ink) <br />Phone Number <br />E-Mail Address <br />Fax Number <br />Date <br />For Anaheim/Santa Ana UASI Grant Coordinator- Use Only <br />Approved for Processing Date <br />Account and Activity Number <br />Grant Year/Grant I Project and Solution Area <br />38 <br />20A-45