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DIVISION OF EMERGENCY MANAGEMENT <br /> 2555 SHUMARD OAK BOULEVARD <br /> TALLAHASSEE , FLORDIA 32399 =21' 00 <br /> CLOSE -OUT REPORT <br /> FORM 5 <br /> This form should be completed and submitted to the Division no <br /> later than sixty ( 60 ) days after the termination date of the Agreement <br /> GRANTEE AGREEMENT # <br /> ADDRESS AGREEMENT AMOUNT <br /> CITY AND STATE AGREEMENT PERIOD <br /> TOTAL FUNDS RECEIVED UNDER THIS AGREEMENT <br /> ` COST CATEGORIES EXPENDITURES DATE AMOUNT <br /> 1 . Planning Costs <br /> 2. Training Costs <br /> 3. Exercise Costs <br /> 4. Organization Costs <br /> 5. Equipment Acquisition Costs <br /> 6. Management and Administration Costs <br /> TOTAL EXPENDITURES $0 . 00 TOTAL $0 . 00 <br /> Total funds received from the Division <br /> of Emergency Management under this <br /> Agreement (Column 4 , Line 7 ) $0 . 00 <br /> Less total grant award expenditures <br /> (Column 2, Line 7 ) $0 . 00 Agreement Amount $0 .00 <br /> Less total funds received <br /> Equals balance of Agreement owed to under this Agreement <br /> . DEM $0 . 00 (Column 4 , Line 7 ) $0 . 00 <br /> . Refund due to State? Yes C No Balance of Agreement $0.00 <br /> If Yes, refund check enclosed ? Yes r No r <br /> I hereby certify that the above costs are true and valid costs <br /> incurred in accordance with the project Agreement, and that <br /> If No , enter date refund will be the matching funds, in-kind or cash, were utilized toward the <br /> submitted project in this Agreement. <br /> Refund and/or final interest check are due no later than ninety (90 ) <br /> days after the expiration date of the Agreement . Signed : <br /> Make check payable to : Cashier, <br /> Division of Emergency Management Date : <br /> Mail to : Division of Emergency Management, 2555 Shumard Oaks Boulevard, Tallahassee, FL 32399-2100 <br />