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FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2021-2022 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM -ABPA DIVISION FORM 5 - CLOSE-OUT REPORT 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. SUB -RECIPIENT: AGREEMENT M POINT OF CONTACT: EMPG AWARD AMOUNT: PHONE/EMAIL: UNCLAIMED BALANCE: ALLOCATION CATEGORIES D(PBNDFURES 1. PLANNING $ _ 2. ORGANIZATION $ - 3. EDUPIv13JT $ - 4. TRAINING $ - 5. EXERCISE $ - 6. MAN14GEM3J7 AND ADMN. $ - AWARD AMOUNT $ (LESS ADVANCED FUNDS) $ (LESS REIMBURSEMENTS) $ UNCLAIMED BALANCE OF AWARD $ RENBURSRAENTS RECEIVED BY TFE SUB - (include any advanced funds and final requested payment) DATE AMOUNT The 2020-2021 EMPG-ARPA agreement has a match requirement of 50% Federal share and 50% Sub -Recipient share of the total award amount. If the EMPG-ARPA award is being matched with EMPA, no additional back-up/supporting documentation is needed to be provided to the Division. If the EMPG-ARPA 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. invoices, 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 thisrepart, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditure; disbursements and cash receipts are for the purposesand objectives set forth in the terms and conditions of the Federal award. lam aware that anyfalse, fictitious or fraudulent Information, or the omission of anymaterial fact, maysubject me to criminal, civil or administrative penalties for fraud, false statement; false claimsor otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections3729-3730 and 3801-3812)." SIGNATURE AND DATE: AUTHORIZED REPRESENTATIVE PRINTED NAE AND TITLE: 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 Mail to: Florida Division of Emergency Management, 2555 Shumard Oak Blvd., Tallahassee, Florida 32399.2100, Attn: (Division Grant Manager) BELOW TO BE COMPLETED BY FDEM: SIGNATURE AND DATE: Diusion Grant Manager SIGNATURE AND DATE: Division Programmatic Reviewer FY 2021-2022 EMPG-ARPA AGREEMENT ATTACHMENT H - REPORTING FORMS 65