Laserfiche WebLink
FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2021-2022 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM -ARPA <br />DIVISION FORM 2A - DETAIL OF CLAIMS <br />SUB -RECIPIENT: INCURRED DATE RANGE: <br />Example: July 1 through Sept. 30, 2021 <br />Please use separate DiNsion Form 2A - Detail of Claims per allocation category. Please protide FEMA AEL numbers for EQUIPMENT expenditures ONLY. <br />Please provide a budget rwAsion to the Division along with this forth, if expenses being claimed are not allocated on the most recently approved budget. <br />Please include the Costs Incurred Date Range in the applicable cell above. This is usually the quarterly period; however, a Sub -Recipient may incorporate a larger date <br />range to include a forgotten claim for reimbursement for a payment made the previous quarter (within the period of the agreement). This allowance does not circumvent the <br />four (4) required reporting submissions. <br />ALLOCATION CATEGORIES <br />PLEASE SELECT FROM THE LIST BELOW <br />CATEGORY: I PLANNING <br /># <br />DATE OF <br />PAYMENT PAYMENT PURCHASE <br />VENDOR DESCRIPTION OF SERVICE OR EXPENSE FOR SERVICE REFERENCE # <br />AMOUNT <br />OR EXPENSE (CHECK #. Fb. CCk. J7) <br />(Include full date) <br />FEMAAEL# <br />ipm <br />(WA d equipment was 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 />"By signing this report I certify to the bestofmy knowledge and beliefthat the reportis true, complete, and accurate, and the expenditures, disbursements and cash receipts are for <br />the purposes and objectives set forth in the terms and conditions ofthe Federal award. 1 am awarethat anylalse, #callous, or fraudulent information, or the omission ofany material <br />fact, may subject me to criminal, civil oradministrative penalties for fraud, false statements, false claims oromermse. (U.S. Code Title 18, Section 1001 and Title 31, Sections <br />3729-3730 and 3801-3812)." <br />SIGNATURE: <br />AUTHORIZED REPRESENTATIVE <br />PRINTED NAME: <br />TITLE: <br />DATE:FY 2021-2022 CM N �� �7 <br />1 <br />ATTACHMENT H - REPORTING FORMS <br />61 <br />