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ATTACHMENT G -REPORTING FORMS
<br />FLORIDA DIVISION OF EMERGENCY MANAGEMENT
<br />2020.2021 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - BASE GRANT
<br />DIVISION FORM 5 - CLOSE-OUT REPORT
<br />Division FORM 5 - CLOSEOUT REPORT shall be completed and submitted to the Division no later than sixty (60) days after the
<br />period of performance ends. The 2020-2021 period of performance ends on June 30, 2021. Division FORM 5 is due by
<br />August 30, 2021.
<br />SUB -RECIPIENT: AGREEMENT #:
<br />POINT OF CONTACT: EMPG AWARD AMOUNT: $
<br />PHONE/EMAIL: UNCLAIMED BALANCE: $
<br />REIMBURSEMENTS RECEIVED BY THE SUB -RECIPIENT
<br />(Include any advanced funds and final requested payment)
<br />ALLOCATION CATEGORIES EXPENDITURES DATE I AMOUNT
<br />$
<br />AWARD AMOUNT $
<br />(LESS ADVANCED FUNDS) $
<br />(LESS REIMBURSEMENTS) $
<br />UNCLAIMED BALANCE OF AWARD $
<br />The 2020-2021 EMPG agreement has a 50% Federal and 50% Local match requirement. If the EMPG award is being matched with EMPA,
<br />no additional back-up/supporting documentation is needed to be provided to the Division. If the EMPG award exceeds the EMPA award or
<br />using local funds for match, the appropriate back-up/supporting documentation for the match fulfillment shall be provided with this form (i.e.
<br />invoices, cancelled checks, earning statements, payroll registries, with amounts clearly identified).
<br />EMPA LOCAL General Revenue LOCAL Other OTHER (Non Federal)
<br />DOTAL rvvy CH I I
<br />SIGNATURE REQUIRED
<br />"By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash
<br />receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award, l am aware that any false, fictitious, or fraudulent information,
<br />or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code
<br />Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812).
<br />SIGNATURE AND DATE:
<br />AUTHORIZED REPRESENTATIVE
<br />PRINTED NAME AND TITLE:
<br />Refund and/or final interest checks are due no later than ninety (90) days after the expiration of the Agreement.
<br />Make checks payable to: Cashier, Florida Division of Emergency Management
<br />Mail to: Florida Division of Emergency Management, 2555 Shumard Oak Blvd., Tallahassee, Florida 32399-2100, Attn: (Division Grant Manager)
<br />.. BELOW TO BE COMPLETED BY FDEM:
<br />SIGNATURE AND DATE:
<br />Division Grant Manager
<br />SIGNATURE AND DATE:
<br />Division Programmatic Reviewer
<br />65
<br />1. PLANNING
<br />$ -
<br />2. ORGANIZATION
<br />$ _
<br />3. EQUIPMENT
<br />$ _
<br />4. TRAINING
<br />$ _
<br />5. EXERCISE
<br />$
<br />fi. MANAGEMENT AND ADMIN.
<br />$ -
<br />$
<br />$
<br />AWARD AMOUNT $
<br />(LESS ADVANCED FUNDS) $
<br />(LESS REIMBURSEMENTS) $
<br />UNCLAIMED BALANCE OF AWARD $
<br />The 2020-2021 EMPG agreement has a 50% Federal and 50% Local match requirement. If the EMPG award is being matched with EMPA,
<br />no additional back-up/supporting documentation is needed to be provided to the Division. If the EMPG award exceeds the EMPA award or
<br />using local funds for match, the appropriate back-up/supporting documentation for the match fulfillment shall be provided with this form (i.e.
<br />invoices, cancelled checks, earning statements, payroll registries, with amounts clearly identified).
<br />EMPA LOCAL General Revenue LOCAL Other OTHER (Non Federal)
<br />DOTAL rvvy CH I I
<br />SIGNATURE REQUIRED
<br />"By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash
<br />receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award, l am aware that any false, fictitious, or fraudulent information,
<br />or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code
<br />Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812).
<br />SIGNATURE AND DATE:
<br />AUTHORIZED REPRESENTATIVE
<br />PRINTED NAME AND TITLE:
<br />Refund and/or final interest checks are due no later than ninety (90) days after the expiration of the Agreement.
<br />Make checks payable to: Cashier, Florida Division of Emergency Management
<br />Mail to: Florida Division of Emergency Management, 2555 Shumard Oak Blvd., Tallahassee, Florida 32399-2100, Attn: (Division Grant Manager)
<br />.. BELOW TO BE COMPLETED BY FDEM:
<br />SIGNATURE AND DATE:
<br />Division Grant Manager
<br />SIGNATURE AND DATE:
<br />Division Programmatic Reviewer
<br />65
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