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Attachment M <br />Close -Out Report Form <br />{ iNL"IAN RIVER COUIJT`( <br />THIS IS TO CERTIFY THAT THIS IS <br />A TRUE AND CORRECT COPY OF <br />TIME O GINAL ON FILE IN THIS <br />J FR CW H, E <br />F Y' <br />- _ 43 <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 #: <br />Areement Amount: $0.00 <br />For Each Deliverable, Enter the Award Amount from Attachment A - Budget and Scope of Work. <br />Cost Category HA Agreement Date or Quarter <br />g ►y Total Amount Paid <br />Deliverable Amounts Completed Per Deliverable <br />Deliverable 1 <br />Deliverable 2 <br />Deliverable 3 <br />Total Deliverables <br />Amount: <br />HA Agreement Amount: <br />Total Paid for <br />Completed Deliverables: <br />$0.00 <br />Amount Previously Paid: I —___1 <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. l 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 & Tide <br />Recipient Signature <br />Date Signed <br />FDEM Grant Manager Signature Date Signed <br />33 RA Attachment M Close -Out Report form 6/6/2022 <br />