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FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2021-2022 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - EMPG BASE GRANT <br />DIVISION FORM 2A -DETAIL OF CLAIMS <br />SUB -RECIPIENT: INCURRED DATE RANGE: <br />Example: July 1 through Sept. 30, 2021 <br />rPlease-use separate Division Fom1 2A Detail of Claims per allocation category. Please pmWde FEMA AEL numbers for EQUIPMENT expenditures ONLY. <br />Please pm%ide a budget revislon to the Dhislon along with this form, if expenses being claimed are not allocated on the most recently appm%ed budget. <br />,-Please include the Costs Incurred Date Range in the applicable cell abme. This is usually the quarterly period; hovm%er, a Sub -Recipient may Incorporate a larger date <br />range to Include a forgotten claim for reimbursement for a payment made the preNous quarter (within the period of the agreement). This allowance does not cimumwnt the <br />four (4) uired reporting submissions. <br />EreqALLOCATION CATEGORIES <br />I PLEASE SELECT FROM THE LIST BELOW <br />CATEGORY: PLANNING <br />_-4-- - ------ J -- <br /># <br />DATE OF <br />PAYMENT PAYMENT PURCHASE <br />VENDOR DESCRIPTION OF SERVICE OR EXPENSE FOR SERVICE REFERENCE # AMOUNT <br />EXPENSE (t]EO(q, PO, CCA, .In <br />Include full date <br />FEMA AEL# <br />(WA N e4uipment vies not <br />purchased) <br />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />9 <br />10 <br />11 <br />12 <br />13 <br />14 <br />15 <br />16 <br />17 <br />18 <br />19 <br />20 <br />TOTAL <br />$ <br />I I I I <br />"'ey signfng tis report, I ce b/y to Me best ofmy knowledge and behefthat the report is <br />true, complete, and a�cumte, and the expenditures, dfsb ursements and cash receipts am for <br />the purposes and objectives set forth in the terms and conditions ofthe Federal award. I am aware that any false, ficti8ous, or fraudulent information, orthe omission ofany material <br />fact, may subject me to criminal, civil or adminisbative penalties for fraud, false statements, false claims or omendse. (U.S. Code Title 18, Section 1001 and Title 31, Sections <br />FY 2021 - 2022 EMPG AGREEMENT <br />ATTACHMENT H- REPORTING FORMS <br />63 <br />