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<br />FY11 Anaheim/ Santa Ana Urban Areas Security Initiative Grant Program <br />Reimbursement Request for Grant Expenditures <br />0 This is the final reimbursement request. <br />Mail Reimbursement Request To: <br />Sgt. Brad Hadley, 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 />Activity Information <br />Projector Class Title(s): <br />Date(s) of Activity or Event: <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 Office Use Only <br />I <br />Approved for Processing Date <br />Account and Activity Number <br />Grant Year/Grant Project and Solution Area <br />Instructions/Comments