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FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2021-2022 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - EMPG BASE GRANT <br />DIVISION FORM 3A - Quarterly Match <br />SUB-RECIPIENT: <br />CLAIM #: <br />1 i <br />QUARTERLY REPORTING PERIOD: July 1 -Sept 30 <br />I I <br />I <br />1. The 2021-2022 EMPG agreement has a match requirement of 50% Federal share and 50% Sub-Recipient share of the total award <br />amount. Each quarterthe Sub-Recipient must identifythe non-federal match amount on the Quarterly Match Form 3A <br />2. If the EMPG funds are being matched with 2021-2022 EMPA claimed a)penditures, no additional back-up/supporting documentation <br />is required to be submitted with this form. <br />3. Ifthe 2021-2022 EMPG award exceeds the 2021-2022 EMPA award, or ifthe Sub-Recipient is not using EMPAdaimed a)penditures to <br />fulfill the EMPG match requirement, appropriate back-up/supporting documentation must accompanythis form to support fulfillment of <br />the required match i.e. invoices, receipts, paystubs, earning statements, cancelled checks, credit card and bank statements, etc. . <br />EMPG REPORTING AWARD AMOUNT: $ 80,000.00 <br />9NPGQUARTERLY CLAIM CUM. RINDS EXPENDED REMAINING BALANCE <br />QUARTER 1 $0.00 $80,000.00 <br />QUARTER 2 $0.00 $80,000.00 <br />QUARTER 3 $0.00 $80,000.00 <br />QUARTER 4 $0.00 $80,000.00 <br />TOTAL EMPG CLAIMS $0.00 <br />EMPA REPORTING AWARD AMOUNT: $ 105,806.00 <br />EIVIPA QUARTERLY CLAIM CUM. RINDS EXPENDED REMAINING BALANCE <br />QUARTER 1 $0.00 $105,806.00 <br />QUARTER 2 $0.00 $105,806.00 <br />QUARTER 3 $0.00 $105,806.00 <br />QUARTER 4 $F.00.'$105 806 00 <br />TOTAL EMPA CLAIMS $0.00 <br />MATCH REPORTING REQUIRED MATCH AMOUNT: $ 40,000.00 <br />EMPA LOCAL General Revenue LOCAL (Other) OTHER Non-Federaq <br />QUARTER 1 <br />QUARTER 2 <br />QUARTER 3 <br />QUARTER 4 <br />TOTAL $0.00 $0.00 $0.00 $0.00 <br />TOTAL MATCH $0.00 7771 <br />"By signing this report, I certify to the best of my knowledge and belief that the reportis true, complete, and accurate, and the expenditures, <br />disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. lam aware that any <br />false, fictitious, or fraudulent information, or the omission of any materia/ fact, may subject me to criminal, civil or administrative penalties for fraud, <br />false statements, false claims or otherwise. (U S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)." <br />SIGNATl1RE <br />AUTHORIZE) REPRESENTATIVE <br />PRINTED NAME <br />TITLE <br />DATE <br />65 <br />