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t OF FLORIDA <br />INDIAN RIVER COUNTY - - - <br />THIS IS TO CERTIFY THAT (rHI9 18 <br />A TRUE ASI CORRECT COPY OF <br />OFFIC V <br />ATTACHMENT M EF EY <br />CLOSE-OUT <br />CLOSE-OUT REPORT FORM BY D.C. <br />2021-2022 HAZARDS ANALYSIS GRANT AGREEM DATE <br />This form should be completed and submitted to the Division no later than sixty (60) days after <br />termination date of the Agreement. <br />SUB -RECIPIENT: Indian River County <br />ADDRESS: 4225 43rd Avenue Vero Beach FL 32967 <br />GRANT # TO 149 <br />AGREEMENT AMT: $1,859.05 <br />For Each Deliverable, Enter the Award Amount from Attachment A - Budget and Scope of Work. <br />COST CATEGORY HA AGREEMENT I DATE OR QUARTER TOTAL AMOUNT PAID <br />DELIVERABLEAMOUNTS COMPLETED PER DELIVERABLE <br />Deliverable 1 $743.62 <br />Deliverable 2 $743.62 <br />Deliverable 3 $371.81 <br />Total Deliverables Total Paid for <br />Amount: $1,859.05 Completed Deliverables: <br />HA AGREEMENT AMOUNT: $1,859.05 <br />AMOUNT PREVIOUSLY PAID: <br />UNUSED BALANCE: <br />By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and <br />the expenditures, disbursements, and cash receipts are for the purposes and objectives set forth in the Terms and <br />Conditions of the State -Funded Hazards Analysis Agreement. I am aware that any false, fictitious, or fraudulent <br />information, or the omission of any material fact, may subject me to criminal, civil, or administrative penalties for fraud, <br />false statements, false claims, or otherwise as proscribed by law. <br />Printed Name & Title <br />Preparer Signature Date Signed <br />Grant Manager Signature Date Signed <br />30 2021-22 HA Attachment At Close -Out Report Form 4/26/2011 <br />