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Attachment N <br />Close Out Report <br />DIVISION OF EMERGENCY MANAGEMENT <br />Hazard Analysis Update Grant 2018-2019 <br />This form should be completed and submitted to the Division no later than sixty (60) days after the <br />termination date of the Agreement. <br />Sub -Recipient <br />Address <br />City and State <br />Cost Categories <br />By Category - Total Agreement <br />Expenditures <br />1. Deliverable 1 <br />2. Deliverable 2 <br />3. Deliverable 3 <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 />Unused balance <br />Agreement No. <br />Agreement Amount <br />Agreement Period <br />Payments Received Under this Agreement <br />(Include any advanced funds and final requested <br />payment) <br />Date Amount <br />$0.00 <br />By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and <br />the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and <br />conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any <br />material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or <br />otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)." <br />Signed <br />Chief Financial Officer or Budget Director <br />Name & Title <br />Date <br />FOR DEM USE: <br />Signed <br />DEM Grant Manager <br />Name 8 Title <br />36 <br />