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A TRUE COPY CERTIFICATION ON LAST PAGE J.R. SMITH, CLERK FY 2022 - 2023 EMPG AGREEMENT ATTACHMENT H REPORTING FORMS 2022-2023 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM DIVISION FORM ZB- DETAIL OF CLAIMS IM11 WW SALARIES AND FRINGE BENEFITS Pay Period: From: To: Sub -Recipient Name: Incurred Date Range: Claim x: DOES THIS CLAIM FOR REIMBURSMENT INCLUDE EXPENSES FOR ANY INCENTIVES OR SPECIAL PAY? Note: H this claim includes Incentives or special pay, please provide FDEM with the written established policy for support. o _ x- C O Y y C U D EM Funded staff Name < LL W $ 15,000.00 SubTotals $ 15,000.00 $ Total Cost Charged to the Grant $ 15,000.00 "By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accurate, and the expenditures, disbursements and cash receipts are for the pruposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fradulent information, or the ommission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1W3 and Title 31, Sections 3729-3730 and 3801-3872)." SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: "By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. 1 am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U. S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)." SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: 64