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FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2021-2022 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - ARPA DIVISION FORM 3A - Quarterly Match SUB -RECIPIENT: QUARTERLY REPORTING PERIOD: July 1 -Sept. 30 CLAIM # 1. The 2021-2022 EMPG-ARPAagreement has a match requirement of 50% Federal share and 50% Sub -Recipient share of the total award amount. Each quarter the Sub -Recipient mustide ntify the non-federal match amount on the Quarterly Match Form 3A 2. Ifthe EMPG-ARPAfunds are being matched with 2021-2022 EMPAclaimed expenditures, no additional back-up/supporting documentation is required to be submitted with this form. 3. Ifthe 2021-2022 EMPG-ARPAaward exceeds the 2021-2022 EMPAaward, or ifthe Sub -Recipient is notusing EMPAclaimed expenditures to fulfill the EMPG-ARPAmatch requirement, appropriate back-up/supporting documentation must accompanythis form to support fulfillment of the required match (i.e. inwices, receipts, paystubs, earning statements, cancelled checks, credit card and bank statements, etc. ). EMPG-ARPA REPORTING AWARD AMOUNT: $ 80,000.00 EMPGARPA QUARTERLY CLAIM CUM. FUNDS EXPENDED REMAINING BALANCE QUARTER 1 $0.00 $80,000.00 QUARTER 2 $0.00 $80,000.00 QUARTER 3 $0.00 F $80,000.00 QUARTER 4 $0.00 $80,000.00 TOTAL EMPG CLAIMS $0.00 $0.00 $0.00 $0.00 EMPA REPORTING AWARD AMOUNT: $ 105,806.00 EMPA QUARTERLY CLAIM CUM. FUNDS EXPENDED REMAINING BALANCE QUARTER 1 $0.00 $105,806.00 QUARTER 2 $0.00 $105,806.00 QUARTER 3 $0.00 $105,806.00 QUARTER 4 _ $0.00 $105,806.00 TOTAL EMPA CLAIMS $0.00 $0.00 $0.00 $0.00 MATCH REPORTING REQUIRED MATCH AMOUNT: $ 40,000.00 EMPA LOCAL (General Revenue) LOCAL (Other) OTHER Non -Federal QUARTER 1 QUARTER 2 QUARTER 3 QUARTER 4 TOTAL $0.00 $0.00 $0.00 $0.00 TOTAL MATCH $0.00 "By signing this report, / certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. lama— that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)." SIGNATURE: PRINTED NAME" TITLE DATE AUTHORIZED REPRESENTATIVE FY 2021-2022 EMPG-ARPA AGREEMENT ATTACHMENT H - REPORTING FORMS 63