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I <br /> 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- I otal Contract <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 /> $0.00 Total 7 $0.00 <br /> Agreement Amount <br /> Minus Total Payments <br /> (Including final requested funds—Line 7) <br /> Unspent balance <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-u /su ortin documentation. <br /> MATCH EMPA LOCAL 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 /> 1 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 /> 2555 Shumard Oak Boulevard Grantee Contract Manager or Financial Officer <br /> Tallahassee,Florida 32399-2100 <br /> Attn: (contract manager) Date <br /> 159 <br />