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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: F1 This is the final reimbursement request. <br />FY10 UASI Grant Program <br />Sgt. Darrin Lee, Grant Coordinator <br />Anaheim Police Department <br />Emergency Management Bureau <br />425 S. Harbor Blvd. <br />Anaheim, CA 92805 <br />FY11 UASI Grant.Program. <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 />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 On[ <br />Approved for Processing Date <br />Account and Activity Number <br />Grant Year/Grant Project and Solution Area <br />Special Instructions/Comments <br />38 <br />20A-43