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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 <br />Address <br />City and State <br />Cost Categories <br />By Category - Total Contract <br />Expenditures <br />Salary and Benefits <br />Other Personal/Contractual <br />Services <br />Expenses <br />Operating Capital Outlay <br />(Equipment) <br />Fixed Capital Outlay <br />EMAP (if applicable) <br />Total <br />$0.00 <br />Total <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 />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />71 $0.00 <br />Agreement Amount <br />Minus Total Payments <br />(Including final requested funds — Line 7) <br />Unspent balance <br />Refund and/or final interest checks are due no later than ninety (90) (lays 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 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 />197 <br />