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DIVISION OF EMERGENCY MANAGEMENT <br /> REIMBURSEMENT REQUEST <br /> FORM 3 - <br /> Grantee Payment Date <br /> Address Agreement # <br /> Payment # <br /> Phone # Awarded Amount $ - <br /> COSTS INCURRED AND PAID DURING THE PERIOD OF : through <br /> THIS MUST BE ACCOMPANIED BY THE DETAIL OF CLAIMS FORM <br /> 1 . Planning Expenditures $ - <br /> 6 <br /> 2 . Training Expenditures $ - <br /> 3 . Exercise Expenditures $ - <br /> 4 . Equipment Expenditures $ - <br /> Management and . Administration Expenditures <br /> 5 . ( limited to 5 % of the total award ) $ - <br /> TOTAL EXPENDITURES $ - <br /> hereby certify that the above costs are true and valid costs incurred in accordance with the project agreement . <br /> Signed : <br /> Contract Manager or Financial Officer Date <br /> TO BE COMPLETED BY DEM STAFF <br /> AGREEMENT AMOUNT $0 . 00 TOTAL AMOUNT TO BE PAID <br /> PREVIOUS PAYMENT( S ) $ 0 . 00 ON THIS INVOICE <br /> THIS PAYMENT $ 0 . 00 <br /> REMAINING BALANCE $ 0 . 00 $0 . 00 <br /> DATE SUBMITTED TO FDEM <br /> Copy of CCP Report Form 2013 <br />