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Attachment N <br />Close -Out Report <br />i � "'- � - :DIVISION OF EMERGENCY MANAGEMENT '— - "' _ 1 <br />Hazard Analysis:Update_Grant 2019-2020 1 <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 />Recipient <br />Address <br />City & State <br />By Category - Total Agreement <br />Cost Categories Expenditures <br />1. Deliverable 1 <br />2. Deliverable 2 <br />3. Deliverable 3 <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 />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 State -Funded Hazards Analysis Agreement. I am aware that any false, fictitious, or fraudulent <br />information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, <br />false statements, false claims or otherwise (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801- <br />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 & Title <br />37 <br />114 <br />