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DIVISION OF EMERGENCY MANAGEMENT <br /> EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT-EMPA BASE GRANT <br /> CLOSE-OUT REPORT <br /> Form 5 <br /> This form should be completed and submitted to the Division no later than forty-five(45)days after the termination date of the <br /> Agreement. <br /> Recipient 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-Total Contract <br /> Cost Categories Expenditures Date Amount <br /> Salary and Benefits <br /> 1 <br /> Other Personal/Contractual <br /> Services <br /> 2 <br /> Expenses <br /> 3 <br /> Operating Capital Outlay <br /> (Equipment) <br /> 4 <br /> Fixed Capital Outlay <br /> 5 <br /> EMAP(if applicable) <br /> 6 <br /> Total <br /> $0.00 Total 7 1 $0.00 <br /> Agreement Amount <br /> Minus Total Payments <br /> (Including final requested funds—Line 7) <br /> Unspent balance <br /> 9 after the expiration of the Agreement. <br /> Refund and/or final interest checks are due no later than nmeh ( 0)days a p g <br /> Make checks payable to:Cashier,Division of Emergency Management <br /> Mail To:Division of Emergency Management,2555 Shumard Oak Boulevard,Tallahassee,Florida 32399-2100,Attn: (contract manager) <br /> I hereby certify that the above costs are true and valid costs incurred in FOR DEM USE: <br /> Signed Signed <br /> Chief Financial Officer or Budget Director DEM Grant Manager <br /> Name&Title Name&Title <br /> Date Date <br />