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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 <br />Address <br />City and State <br />Cost Categories <br />By Category - Iota' Contract <br />Expenditures <br />1 Organizational Activities <br />2. Planning Activities <br />3. Training Costs <br />4 Exercise Costs <br />5. Equipment Acquisition Costs <br />6. Management and <br />Administration Costs <br />Total <br />$0.00 <br />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />Total 7 <br />Agreement Amount <br />Minus Total Payments <br />(Including final requested funds — Line 7) <br />Unspent balance <br />Agreement No <br />Agreement Amount <br />Agreement Period <br />Payments Received Under this Agreement <br />(Include any advanced funds and final requested payment) <br />Date Amount <br />$0.00 <br />Federal funds provided under this Agreement shall be matched by the Recipient dollar for dollar from non-federal funds. NOTE. If the <br />amount entered below is NOT EMPA, provide appropriate back-up/supporting documentation. <br />MATCH <br />EMPA <br />LOCAL <br />OTHER NON-FEDERAL <br />Refund and/or final interest checks are due no later than ninety (90) days after the expiration of the Agreement. <br />Make checks payable to: <br />Cashier, Division of Emergency Management <br />Mail To: <br />Division of Emergency Management <br />2555 Shumard Oak Boulevard <br />Tallahassee, Florida 32399-2100 <br />Attn: (contract manager) <br />I hereby certify that the above costs are true and valid costs incurred in <br />accordance with this Agreement. <br />Signed <br />Date <br />Grantee Contract Manager or Financial Officer <br />