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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 S - CLOSE-0UT 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 -Close Out Report is <br />due by August 30, 2021. <br />SUB -RECIPIENT: <br />POINT OF CONTACT: <br />AGREEMENTill: <br />EMPG AWARD AMOUNT: S <br />PHONEJEMAIL: UNCLAIMED BALANCE: <br />ALLOCATION CATEGORIES <br />EXPENDITURES <br />1 PLANNING <br />$ _ <br />ORGAN12AT ON <br />$ - <br />EOUPMENT <br />$ <br />fRANIW_ <br />$ - <br />AWARD AMOUNT $ <br />(LESS ADVANCED FUNDS) $ <br />(LESS REIMBURSEMENTS) S <br />UNCLAIMED BALANCE OF AWARD S <br />RFIMR IRSFh1 FNT5% RFCFNFrIRY THF fAI"FCIPFNT <br />AMOONT <br />5 - <br />S <br />S - <br />The Division Form 5 - Close Out Report is due within sixty (60) days after the period of agreement ends. The 2020-2021 EMPG-S <br />agreement has a 59% Federal and 50% Local match requirement. Ifthe EMPG-S award is being matched with EMPA. no additional back- <br />up/supporting documentation is needed to be provided to the Division. If the EMPG-S award exceeds the EMPA award or using local funds <br />for match. the appropriate back-uptsupporting documentation forthe match fulfillment shall be provided with this form (i.e. invoices, <br />cancelled checks, earning statements, payroll registries, with amounts clearly identified). <br />TOTAL MATCH <br />SIGNATURE REQUIRED <br />"By Wining this report. I cmtdy to the best o1 my Arowledge and belie/ that the repon is true. COM01 a and aecumae, Wd Me exp enti ale for the purpose! and <br />db3aetNes eat r" in the fume and eehadfont olthe Feduaf —el, f am aWale eIN any false, ii-ti—it dr rmuduient freormaflar, tithe Dm(STlen of ally marenaf <br />fact may subject me rechannel, co -M oradminiarrarivs penaiflstrfrit frau/, !else atafemenla false dorms w ethenvis 1, IV.S Code Tide 18, Section 1001 and Title 31, <br />Sections 3720-9730 and 9801-3012)." <br />SIGNATURE AND DATE <br />AUTHORIZED REPRESENTATIVE <br />PRINTED NAME AND TITLE: <br />Refund andfor sinal 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 m: Florida Oivirion al Emuserx:y MenegemeM, 2556 Shumefd Oak Blvd-. Tellehpeea. Florlda 32 999 2 100. Attn'. (Dlvlalon Cront Manager) <br />BELOW TO BE COMPLETED BY DIVISION: <br />SIGNATURE AND DATE: <br />Division Grant Manager <br />SIGNATURE AND DATE: <br />Division Programmatic Reviewer <br />NE <br />