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Appendix IV Financial Reimbursement of Expenditures Reporting Form <br />Prepare an itemized request for reimbursement expenditures in each budget categories for each deliverable. Attach copies of purchase orders and paid <br />vouchers, invoices, copies of checks, journal transfers, required for expenditure justifications. If there is insufficient space, please include details in an <br />attachment. <br />County: <br />Grant Number: <br />Request Number: <br />Request Date: <br />Budget Categories <br />Deliverable Items <br />Unit Price ($) <br />Quantity <br />Total Amount ($) <br />Previous Request <br />Amount ($) <br />Current Request <br />Amount ($) <br />A. Systems (Hardware, Software, Equipment & Labor) <br />B. Services (Training, Maintenance and Warranty Items) <br />Grant Request Total <br />Justification for Progress Disbursement {if applicable} <br />• <br />I certified that a <br />1 invoice items have been received and <br />completed. <br />Signature, County 911 Coordinator <br />Application for E911 State Grant Program , revised 01/2018 <br />Page 21 <br />W Form 3A, incorporated by reference in Fla. Admin. Code R. 6OFF1-5.003 E911 State Grant <br />