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FY 2021-2021 EMPA AGREEMENT <br />ATTACHMENT J -REPORTING FORMS <br />FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2021-2022 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE - EMPA <br />DIVISION FORM 1A -QUARTERLY FINANCIAL REPORT <br />AGREEMENT #: <br />CLAIM #: 1 <br />AWARD AMOUNT: <br />QUARTER #:1 1 <br />RECIPIENT: <br />REPORTING FORMS DUE DATES (45 DAYS AFTER QUARTER) <br />COUNTY:{ <br />1. July 1 - Sept. 30, 2021 = November 15, 2021 <br />{ j 2. October 1 - Dec. 31, 2021 = February 15, 2022 <br />3. January 1 - March 31, 2022 = May 15, 2022 <br />4. April 1 - June 30, 2022 = August 15, 2022 <br />123@i;mail.com { <br />ADDRESS: <br />POINT OF CONTACT: <br />PHONEIEMAIL:{ <br />{ <br />CUMULATIVE <br />EMPA ALLOCATION CATEGORIES BUDGETED 01 CLAIM Q2 CLAIM 03 CLAIM Q4 CLAIM EXPENDED FUNDS REMAINING <br />ALLOCATIONS BALANCE <br />1. PLANNING $0.00 $0.00 $0.00 <br />2. ORGANIZATION $0.00 $0.00 $0.00 <br />3. EQUIPMENT $0.00 $0.00 $0.00 <br />4. TRAINING $0.00 $0.00 $0.00 <br />5. EXERCISE $0.00 $0.00 $0.00 <br />6. MANAGEMENT AND ADMIN. U to 5*14 $0.00 $0.00 $0.00 <br />TOTAL $0.00 $0.00 $0.00 r $0.00 $0.00 $0.00 $0.00 <br />AMOUNT OF REIMBURSEMENT FOR THIS CLAIM: <br />By signing this report, l certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements <br />and cash receipts are for the purposes and objectives set forth in the conditions of the 2021.2022 EMPA agreement. <br />SIGNATURE <br />AUTHORIZED REPRESENTATIVE <br />DATE <br />QUARTERLY STATUS REPORT <br />Please report EM activities, meetings, training,exercises, or other necessary information to support quarterly progression. <br />THE SECTION BELOW IS TO BE COMPLETED BY DIVISION <br />AWARD AMOUNT <br />PRIOR CLAIMS <br />THIS CLAIM AMOUNT <br />BALANCE OF AWARD <br />DIVISION DATE RECEIVED STAMP _ <br />3� <br />