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ATTACHMENT G - REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2020-2021 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - EMPG BASE GRANT DIVISION FORM 2A - DETAIL OF CLAIMS SUB -RECIPIENT: INCURRED DATE RANGE: Example: July 1 through Sept 30 2020 Please use separate Division Form 2A - Detail of Claims per allocaton category. Please provide FEMA AEL numbers for EQUIPMENT expenditures ONLY. Please provide a budget revision to the Division along with this form, if expenses being claimed are not allocated on the most recently approved budget Please include the Costs Incurred Date Range in the applicable cell above. This is usually the quarterly period; however, a Sub -Recipient may incorporate a larger date range to include a forgotten claim for reimbursement for a payment made the previous quarter (within the period of the agreement). This allowance does not circumvent the four (4) required reporting submissions. ALLOCATION CATEGORIES PLEASE SELECT FROM THE LIST BELOW CATEGORY: PLANNING # DATE OF PAYMENT PAYMENT PURCHASE FEMA AEI-# VENDOR DESCRIPTION OF SERVICE OR EXPENSE FOR SERVICE REFERENCE # (ry�n lraw�AE ares not OR EXPENSE (CHECK k, PO, CCa, ,1T) AMOUNT p„«hased/ (A Clude fdl date) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTAL "By signing this report, I certUy to the best of my kwvdedge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. / am avare that any fa/se, fictitious, of fraudulent information, or the omission of any materia/ fact, may subject me to criminal, civil or administrative penalties Por fraud, false statements, false claims or omermse. WS Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812).' SIGNATURE: -- _ AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: 61