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ATTACHMENT M <br />CLOSE-OUT REPORT FORM <br />2020-2021 HAZARDS ANALYSIS GRANT AGREEM <br />OF FLORIDA <br />f iWDIAN RIVER COUNTY <br />A TRUE AND CORRECT COPY OF <br />rHE ORIGINAL ON FILE IN THIS <br />OFFICE. <br />,EFFRE,Y R. SkRrH ci Gau <br />:.-ATE _ <br />This form should be completed and submitted to the Division no later than sixty ( <br />termination date of the Agreement. <br />SUB -RECIPIENT: Indian River County <br />ADDRESS: <br />GRANT # T0097 <br />D <br />AGREEMENT AMT: $2,913.00 <br />For Each Deliverable, Enter the Award Amount from Attachment A - Budget and Scope of Work. <br />COST CATEGORY HA AGREEMENT DATE SUBMITTED TOTAL AMOUNT PAID <br />DELIVERABLEAMOUNTS I I PER DELIVERABLE <br />Deliverable 1 $1,165.20 <br />Deliverable 2 $1,165.20 <br />Deliverable 3 $582.60 <br />Total Deliverables Total Paid for <br />Amount. $2,913.00 Completed Deliverables; $0.00 <br />HA AGREEMENT AMOUNT: <br />$2,913.00 <br />AMOUNT PREVIOUSLY PAID: <br />$0.00 <br />UNUSED BALANCE: <br />$2,913.00 <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 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 as proscribed by law. <br />Printed Name & Title <br />Signature Date Signed <br />40 2020-21 HA Attachment M Close -Out Report Form Updated 6/10/2020 <br />.c. <br />