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ATTACHMENT G — REPORTING FORMS <br />FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2020-2021 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - EMPG BASE GRANT <br />DIVISION FORM 3A - Quarterly Match <br />SUB -RECIPIENT: <br />QUARTERLY REPORTING PERIOD: July 1 - Sept. 30 <br />CLAIM # <br />1. The 2020-2021 EMPG agreement has a 50% Federal and 50% Local match requirement. Each quarter the Sub -Recipient must identify the non- <br />federal match on the Quarterly Match Form 3A <br />2. If the EMPG funds are being matched with 2020-2021 EMPA claimed expenditures, no additional back-up/supporting documentation is required to <br />be submitted with this form. <br />3. If the 2020-2021 EMPG award exceeds the 2020-2021 EMPA award, or if the Sub -Recipient is not using EWA claimed expenditures to fulfill the <br />EMPG match requirement, appropriate back-up/supporting documentation must accompany this form to support fulfillment of the required match <br />(i.e. invoices, receipts, paystubs, earning statements, cancelled checks, credit card and bank statements. etc. I. <br />EMPG REPORTING <br />AWARD AMOUNT: <br />$ <br />EMPG QUARTERLY CLAIM <br />CUM. FUNDS EXPENDED <br />REMAINING BALANCE <br />QUARTER 1 <br />$0.00 <br />$0.00 <br />QUARTER 2 <br />$0.00 <br />$0.00 <br />QUARTER 3 <br />$0.00 <br />$0.00 <br />QUARTER 4 <br />$0.001,$105,806.00 <br />TOTAL EMPG CLAIMS $0.00 <br />EMPA REPORTING <br />AWARD AMOUNT: <br />$ 105,806.00 <br />EMPAQUARTERLY CLAIM <br />CUM. FUNDS EXPENDED <br />REMAINING BALANCE <br />QUARTER 1 <br />$0.00 <br />$105,806.00 <br />QUARTER 2 <br />$0.00 <br />$105,806.00 <br />QUARTER 3 <br />$0.00 <br />$105,806.00 <br />QUARTER4 <br />$0.001,$105,806.00 <br />TOTAL EMPA CLAIMS $0.00 <br />mAI UH KLI'UKI ING REQUIRED MATCH AMOUNT: $ <br />QUARTER 1 EMPA LOCAL (General Revenue) LOCAL (other) OTHER (Non -Federal) <br />QUARTER 2 <br />QUARTER 3 <br />QUARTER 4 <br />TOTAL $0.00 $0.00 $0.00 $0.00 <br />TOTAL MATCH $0.00 <br />i'By signing this report, I certify to the best of my knovdedge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and <br />cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal aKerd. 1 am amre that any false, fictitious, or fraudulent <br />information, or the omission of any material fact, may subject me to criminal, civic or administrative penalties for fraud, false statements, false claims or othermse. <br />(U. S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812).' <br />SIGNATURE: <br />AUTHORIZED REPRESENTATIVE <br />PRINTED NAME: <br />TITLE: <br />DATE: <br />63 <br />