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FY 2021 - 2022 EMPG AGREEMENT <br />ATTACHMENT H- REPORTING FORMS <br />FLORIDA:DIVISION OF EMERGENCY MANAGEMENT <br />2021-2022 EMERGENCY MANAGEMENT PERFORMANCE GRANT -EMPG BASE GRANT <br />DIVISION FORM 1 A -QUARTERLY FINANCIAL REPORT <br />AGREEMENT #: I i CLAIM #: <br />1 <br />_ <br />AWARD AMOUNT:' I QUARTER #: <br />1 <br />SUB -RECIPIENT:! j <br />COUNTY:; REPORTING FORMS DUE DATES (30 DAYS AFTER QUARTER) <br />ADDRESS:1 1 - July 1 - Sept 30, 2021 (Forms are due no later than October 30) <br />I <br />I 2 - October 1 - Dec. 31, 2021 -(Forms are due no later than January 30) <br />_ <br />3 - January 1 -March 31, 2022 (Forms are due no later than April 30) <br />POINT OF CONTACT: <br />! 4 - April 1 - June 30, 2022 (Forms are due no later than Juy 30) <br />PHONEIEMAILJ <br />EMPG ALLOCATION CATEGORIES BUDGETED 01 CLAIM <br />ALLOCATIONS <br />02 CLAIM 03 CLAIM Q4 CLAIM CUMULATIVE REMAINING <br />EXPENDED FUNDS BALANCE <br />1. PLANNING $0.00 <br />$0.00 $0.00 <br />2. ORGANIZATION $0.00 <br />$0.00 $0.00 <br />3. EQUIPMENT $0.00 <br />$0.00 $0.00 <br />4. TRAINING $0.00 <br />$0.00 $0.00 <br />S. EXERCISE $0.00 <br />$0.00 $0.00 <br />6. -MGMT AND ADMIN (up to 5W $0.00 <br />$0.00 $0.00 <br />TOTAL $0.00 $0.00$0.00 <br />$0.00 $0.00 $0.00 _ $0.00 <br />AMOUNT OF REIMBURSEMENT FOR THIS CLAIM: �- <br />"By signing ths report. I certify to the best of my Ino. ledge and beflef 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 aw ard. I am aware that any false, fictitious, or fraudulent information, or <br />the omission of any material fact, may subject me to crirrinal, civil or adrrinstrative penalties for fraud, false statements, false claims or otherw Ise. (U.S. Code Title 18, <br />!Section 1001 and Tits 31, Sections 3728-3730 and 3801-3812)." r <br />i <br />I <br />SIGNATURE 1, <br />AUTHORIZED REPRESENTATIVE DATE <br />QUARTERLY STATUS REPORT <br />Please report EM activities, meetings, training, exercises, or other necessary information to support quarterly pixigression. <br />THE SECTION BELOW IS TO BE COMPLETED BY THE DIVISION <br />AWARD AMOUNT 1 <br />DIVISION DATERECBV®STAMP <br />MENT <br />PRIOR CLAIMS <br />THIS CLAIM AMOUNT <br />BALANcOf A32ft 1 2022 EMPG AGREi <br />A TTAGHMENT, H- REPORl1NG FORMS <br />61 <br />