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Attachment D <br />DIVISION OF EMERGENCY MANAGEMENT <br />REQUEST FOR ADVANCE OR REIMBURSEMENT OF <br />HAZARD MITIGATION ASSISTANCE PROGRAM FUNDS <br />SUB -RECIPIENT: INDIAN RIVER COUNTY <br />REMIT ADDRESS: <br />CITY: STATE: ZIP CODE: <br />PROJECT TYPE: WILDFIRE MITIGATION PROJECT#: 4823-95-R <br />PROGRAM: Hazard Mitigation Grant Program CONTRACT #: H0259 <br />APPROVED BUDGET: FEDERAL SHARE: MATCH: <br />ADVANCED RECEIVED: N/A AMOUNT: SETTLED? <br />Invoice Period: To Payment #: <br />Eligible Amount <br />100% <br />(Current Request) <br />Obligated Federal <br />Amount <br />75.0% <br />Obligated Non- <br />Federal <br />25.0% <br />Division Use Only <br />Approved <br />Comments <br />TOTAL CURRENT REQUEST: $ <br />By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, <br />and 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 />SUB -RECIPIENT SIGNATURE: <br />NAME / TITLE: <br />APPROVED PROJECT TOTAL <br />ADMINISTRATIVE COST $ <br />APPROVED FOR PAYMENT $ <br />DATE: <br />TO BE COMPLETED BY THE DIVISION <br />GOVERNOR'S AUTHORIZED REPRESENTATIVE <br />DATE <br />173 <br />