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ATTACHMENT G - REPORTING FORMS <br />FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2020-2021 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM, COVID-19 SUPPLEMENTAL <br />DIVISION FORM 3A -Quarterly Match <br />SUB -RECIPIENT: <br />QUARTERLY REPORTING PERIOD: July 1 • Sept. 30 <br />CLAIM #: <br />1. The 20262021 EMPG-S agreement has a 50% Federal and SD% Local match requirement. Each quarter the Sub -Recipient must identify the Local <br />match on the Quarterly Match Farm 3A. Unless otherwise authorized bylaw, Federal funds cannot be matched with other Federal funds. <br />2. If the EMPG-S funds are being matched with 20262021 EMPA claimed expenditures. no additional back-uplsuppating documentation is required <br />,to be submitted with this form. <br />$. If the 20262021 EMPG-S award exceeds the 20262021 EMPA award, or if the Sub -Recipient is not using EMPA claimed expenditures to fulfill <br />the EMPG-S match requirement. appropriate back-uphuppating documentation must accompany this form to support fulfillment of the required <br />match (i.e. invoices, receiptspaystubs, earning statements, cancelled cheeks, credit card and bank statements, etc. I. <br />EMPG-S REPORTING <br />AWARD AMOUNT: <br />$ <br />EMPA QUARTERLY CLAIM <br />EMPG 5 QUARTERLY CLAIM CUM. FUNDS EXPENDED <br />REMAINING BALANCE <br />QUARTER '' <br />$c 00 <br />50.00 <br />QUARTER 2 <br />$c 00 <br />$0.00 <br />QUARTER 3 <br />SO 00 <br />$0.00 <br />QUARTER 4 <br />$000 <br />$0.00 <br />TOTAL MATCH $0.00 <br />TOTAL EMPG-S CLAIMS <br />S000 <br />EMPA REPORTING <br />AWARD AMOUNT: <br />$ 105 806.00 <br />EMPA QUARTERLY CLAIM <br />CUM. FU N DS EX PEN DED <br />REMAINING BALANCE <br />QUARTER' <br />$000 <br />$105-806.00 <br />QUARTER 2 <br />S000 <br />$105.806.00 <br />QUARTER 3 <br />$0.00 <br />$105.806.00 <br />QUARTER 4 <br />$000 <br />$105.806.00 <br />TOTAL MATCH $0.00 <br />TOTALEMPACLAIM181 $0.00 <br />MATCH REPOKTINGREQUIRED <br />MATCH AMOUNT: $ <br />EMPA <br />LOCAL iGenerallliiviinue) LOCALiOtherl OT HERMorrFederab <br />QUARTER 1 <br />QUARTER 2 <br />QUARTER 3 <br />QUARTER 4 <br />TOTAL 50.00 <br />$000 50.00 50.00 <br />TOTAL MATCH $0.00 <br />"81 sgnfng tars rep0111 0001101 to Me 00sr of m y xnoW7edge akW DB1p/rha2 the niport a llfl6, romPAM. Ono aceurxQ. and me o lonfldrat aro for rho pu/Poaes and <br />0001ves set forth ak the leans and rnndt,ons dithe Federal evrew IS- eviare feel any fairercttioua, orfraudoleM information, orthe omeson of enymaterel <br />fact. may subject me to crnnmal. owl err admmatr "pereties for fraud. faae statements, /alae clams or orhemweI V.S. Code TMe 18, Sectim 1001 and Tile 31, <br />Sections 3729-3730 end 3801-38121.' <br />SIONATURE: <br />PRINTED NAME: <br />TITLE: <br />DATE: <br />AUTHORIZED REPRESENTATIVE <br />57 <br />