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FY 2021 - 2022 EMPG AGREEMENT ATTACHMENT'H- REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2021-2022 EMERGENCY MANAGEMENT iPERFORMANCE GRANT PROGRAM - BASE GRANT DIVISION FORM 5 - CLOSE-OUT REPORT h; Division FORM 5 - CLOSEOUT REPORT shall be completed and submitted to the Division no later than sixty (60) days after the, period of performance ends. The 2021-2022 period of performance ends on June 30, 2022. Division FORM 5 is due by August 30, 2022. i SUB-RECIPIENT:I I AGREEMENT #:I ? POINT OF CONTACT: i EMPG AWARD AMOUNT:! $ PHONE/EMAIL:i UNCLAIMED BALANCE: $ I REIvBLRSEvENTS PBMVED BY THE SUE- ll&(include (includeany advanced funds and final requested payment) ALLOCATION CATEGORIES DOTENIDRURES i DATE AMDLINT 1. PLAMINC $ _ i 7 $ _ 2. ORGANIZATION $ _ 2 $ _ 3. e0LIPv NT $ _ 3 $ _ 4. TRAINING $ - 4 $ _ 5. EXERCISE_ $ 5 $ 6. MANAGEMENT AND AOMIIN. $ _ 6 $ _ $ - I $ - I AWARD AMOUNT $ ' (LESS ADVANCED FUNDS) $ (LESS REIMBURSEMENTS) $ UNCLAIMED BALANCE OF AWARD' $ r The 2021-2022 EMPG agreement has a match requirement of 507 Federal and 50% Sub -Recipient share of the total award amount. if the EMPG award is being matched with EMPA, no additional back-up/supporting documentation is needed to be pmvided to the Division. If the EMPG award exceeds.the EMPA award or using local funds for match, the appropriate back-up/supporting documentation for the match fulfillment shall be provided with this form (i.e. imoices, cancelled checks, earning statements, payroll registries, with amounts clearly identified). EMPA LOCAL General.Revenue LOCAL Other OTHER Non -Federal TOTAL MATCH SIGNATURE REQUIRED "By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the mpendl tura; disbursements and cash receipts are for the purposes and objectives set forth In the terms and conditions of the federal award. I am aware that any false, ffctl tlou; or fraudulent Information, or the omission of any material fad, may subject me to criminal, civil or administrative penalties for fraud, false statement; false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3724)730 and 3801-3812)." SIGNATURE AND DATE:I i AUTHORIZED REPRESENTATIVE PRINTED NMAE AND TITLE: I { I I I I Refund and/or final Interest checks are due no later than ninety (90) days after the expiration of the Agreement. Make checks payable to: Cashier, Florida Division of Emergency Management Mall to: Florida Division of Emergency Management, 2555 Shumard Oak Blvd., Taflahasses, Florida 32398-2100, Attn: (Division Grant Manager) BELOW TO BE COMPLETED BY FDEM: SIGNATURE AND DATE: r Division Grant Manager { � 1 SIGNATURE AND DATE: Division Programmatic Reviewer I �' I i 67