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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />J.R. SMITH, CLERK <br />FY 2022 - 2023 EMPG AGREEMENT <br />ATTACHMENT H <br />REPORTING FORMS <br />FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2022-2023 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - EMPG BASE GRANT <br />DIVISION FORM 2A- DETAIL OF CLAIMS <br />SUB -RECIPIENT: <br />INCURRED DATE RANGE: Example: duly 1 through Sept. 30 2022 <br />Please use separate DhAsion Forth 2A - Detail of Claims per allocation category. Please protide FEMA AEL numbers for EQUIPMENT expenditures ONLY. <br />Please protide a budget retision to the Di4sion along with this form, if expenses being claimed are not allocated on the most recently approxed budget. <br />Please include the Costs Inured Date Range in the applicable cell above. This is usually the quarterly period; howe%er, a Sub -Recipient may incorporate a larger date <br />range to include a forgotten claim for reimbursement for a payment made the premous quarter (within the period of the agreement). This allowance does not circumvent the <br />four (4) required reporting submissions. <br />ALLOCATION CATEGORIES <br />PLEASE SELECT FROM THE LIST BELOW <br />CATEGORY: I PLANNING <br /># <br />DATE OF <br />PAYMENTPAYM BdT' PURCHASE <br />VENDOR DESCRIPTION OF SERVICE OR EXPENSE FOR SERVICE REFERENCE # AMOUNT <br />OR EXPENSE fCHEa<u, �. Ml. JTr, <br />(Include full dale) <br />FEMA AEL# <br />(WA if equo—ntwas not <br />purchased) <br />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />9 <br />10 <br />11 <br />12 <br />13 <br />14 <br />15 <br />16 <br />17 <br />18 <br />19 <br />20 <br />TOTAL <br />"By signing this report, I certify to the best ofmy knowledge and beliefthat the report is We, complete, and accurate, and the expenditures, disb ursements and cash receipts are for <br />Via purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, orthe omission ofany material <br />fact, may subject me to criminal, civil oradmmisbative penalties forlmud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections <br />3729-3730 and 3801-3812).' <br />SIGNATURE: <br />AUTHORIZED REPRESENTATIVE <br />PRINTED <br />DATE: <br />63 <br />