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Division of Emergency Management <br /> 2555 Shumard Oak Boulevard <br /> Tallahassee , Florida 32399 -2100 <br /> EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - BASE GRANT <br /> CLOSE-OUT REPORT <br /> FORM 4 <br /> This form should be completed and submitted to the Division no later than forty -five (45) days after the termination date of <br /> the Agreement. <br /> Grantee Agreement No . <br /> Address Agreement Amount <br /> City and State Agreement Period <br /> Payments Received Under this Agreement <br /> (Include any advanced funds and final requested payment) <br /> By Category - ota ontract <br /> Cost Categories Expenditures Date Amount <br /> 1 . Organizational Activities <br /> 1 <br /> 2 . Planning Activities <br /> 2 <br /> 3 . Training Costs <br /> 3 <br /> 4 . Exercise Costs <br /> 4 <br /> 5 . Equipment Acquisition Costs <br /> 5 <br /> 6 . Management and <br /> Administration Costs 6 <br /> Total <br /> $0 . 001 Total 7 $0 . 00 <br /> Agreement Amount <br /> Minus Total Payments <br /> (Including final requested funds — Line 7) <br /> Unspent balance <br /> Refund and/or final interest checks are due no later than ninety <br /> (90 ) days after the expiration of the Agreement. <br /> Make checks payable to : <br /> Cashier, Division of Emergency Management <br /> I hereby certify that the above costs are true and valid costs incurred in <br /> accordance with this Agreement. <br /> Mail To : <br /> Division of Emergency Management Signed <br /> Grantee Contract Manager or Financial Officer <br /> 2555 Shumard Oak Boulevard <br /> Tallahassee, Florida 32399-2100 <br /> Attn : (contract manager) Date <br />