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Attachment M <br />Close -Out Report Form <br />2022-2023 Hazard Analysis Grant Agreement <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: <br />Grant Agreement #: Areement Amount: $0.00 <br />For Each Deliverable, Enter the Award Amount from Attachment A - Budget and Scope of Work <br />Cost Category <br />HA Agreement <br />Deliverable Amounts <br />Date or Quarter <br />Completed <br />Total Amount Paid <br />Per Deliverable <br />Deliverable 1 <br />Deliverable 2 <br />Deliverable 3 <br />Total Deliverables <br />Total Paid for <br />Amount. <br />Completed Deliverables: <br />HA Agreement Amount: <br />$0.00 <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, <br />and 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 />Recipient Printed Name & Title <br />Recipient Signature Date Signed <br />FDEM Grant Manager Signature Date Signed <br />48 <br />HA Attachment M Close -Out Report Form 6/6/2022 <br />