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FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2021.2022 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA <br />DIVISION FORM 6-CLOSEOUT REPORT <br />DIVISION FORM 5 -CLOSEOUT REPORT shall be completed and submitted to the Division no later than sixty (60) days atter the <br />termination date of the agreement. The 2021.2022 period of agreement ends on June 30, 2022. DMSION Form 6 is due by <br />August30,2022. <br />RECIPIENT:1 <br />AGREEMENT#: <br />POINT OF CONTACT:1 <br />IEMPAAWARD AMOUNT: <br />PHONE/EMAIL: <br />JUNCLAIMED BALANCE: <br />] WURSENBNMRECEIVED BYTHERECIR <br />(Include any advanced funds and final requested payment) <br />ALLOCATIONCATEGORIES <br />ALLOCATIONS <br />DATE AMOLINT <br />1. PLANNNG <br />$ <br />$ <br />2.ORGANZATION <br />3.TRAINNG <br />4. EXERCISE <br />5. E3.IUIPNIENT <br />6. MANAGEMENTANDADM. <br />$ <br />$ <br />AWARD AMOUNT: <br />$ - <br />(LESS ADVANCED FUNDS) <br />(LESS REIMBURSEMENTS)I <br />r <br />$ - <br />UNCLAIMED BALANCE OF AWARD <br />$ <br />In accordance with Rule 27819.011, Florida Administrative Code, base grants shall be matched at an amount either equal to the average of the <br />previous three years' level of county general revenue funding of the County Emergency Management Agency or the level of funding for the County <br />Emergency Management Agency for the last fiscal year, whichever is lower. Required with this form, the county needs to provide a copy of the <br />current EM local budget (general revenue) and general ledger expenditure report as of 6/302022. <br />REMENT <br />2027-2022 <br />LOCAL <br />2020-2021 <br />LOCAL <br />2019.2020 201&2019 <br />LOCAL LOCAL <br />AVERAGEOF <br />PREVIOUS <br />3YEARS <br />2021.2022 EM LOCAL <br />GENERALRB/ENUE <br />EXPENDITURES <br />E rnple: FL County <br />SIGNATURE REQUIRED <br />By signing this report, I certify to the bast of my knowledge and belief that the report is true, complete, accurate and the expenditurett <br />disbursements and cash receipts are for the purposes and objectives sot forth in the conditions of the 2021-2022 EMPA agreement. <br />SIGNATURE AND DATE: <br />AUrHORZED FEPRESENTATIVE <br />PRINTED NANE AND TITLE <br />Refund and/or final Interest checks are due no later than ninety (90) days after the expiration of the agreement. Please submit this <br />form and supporting documentation to: Florida Division of Emergency Management, 2666 Shumard Oak Blvd., Tallahassee, FL 32399, <br />Attn: (Division Grant Manager) <br />BB.OW TO BE COMPLETED BY DIVISION <br />SIGNATURE AND DATE:) <br />DIVISION GRANT MANAGER <br />SIGNATURE A ND DAT(= <br />DIVISION PROGRAMMATIC REVIEWER <br />