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i <br /> DIVISION OF EMERGENCY MANAGEMENT <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 the <br /> Agreement. <br /> Sub-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- 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 Sub-Recipient dollar for dollar from non-federal funds. If <br /> the funds are being matched with EMPA and are less than the expended EMPA, no additional back-up/supporting <br /> documentation is needed. However, if your EMPG funds exceed EMPA, or if you are not using EMPA for match,the appropriate <br /> back-up/supporting documentation needs to be provided (i.e.general ledger with highlighted matching non-federal funds). <br /> MATCH EMPA LOCAL(General Revenue) LOCAL(other) 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: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 and that FOR DEM USE: <br /> the match requirements have been met in accordance with this Agreement. Reconciliation and verification of EMPG funds <br /> Signed Signed <br /> Chief Financial Officer or Finance Director DEM Grant Manager <br /> Name&Title Name&Title <br /> Date Date <br />