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A TRUE COPY CERTIFICATION ON LAST PAGE J R. S101TH, CLERK FY 2022 - 2023 EMPG AGREEMENT ATTACHMENT H REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2022-2023 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - EMPG BASE GRANT DIVISION FORM 3A - Quarterly Match SUB -RECIPIENT: QUARTERLY REPORTING PERIOD: July 1 -Sept. 30 CLAIM #: 1. Federal funds provided under the 2022-2023 EMPG agreements hall be matched by the Sub -Recipient (dollar -for -dollar) totaling the award amount. Each quarter the Sub-Recipientm us tidentify the non-federal match amount on the Quarterly Match Form 3A 2. If the EMPG funds are being matched with 2022-2023 EMPA claimed expenditures, no additional back-up/supporting documentation is required to be submitted with this form. 3. If the 2022-2023 EMPG award exceeds the 2022-2023 EMPAaward, or if the Sub -Recipient is not using EMPAclaimed expenditures to fulfill the EMPG match requirement, appropriate back-up/supporting documentation must accompanythis form to support fulfillment ofthe required match (i.e. invoices, receipts, paystubs, earning statements, cancelled checks, credit card and bank statements, etc. ). EMPG REPORTING AWARD AMOUNT: $ 105,806.00 _ EMPG QUARTERLY__CLAIM CUM. FUNDS EXPENDED REMAINING BALANCE QUARTER 1 $0.00 $0.00 QUARTER 2 $0.00 $0.00 QUARTER 3 _ QUARTER 4 _ _ $0.00 $0.00 $0.00 $0.00 TOTAL EMPG CLAIMS $0.00 $0.00 $105,806.00 EMPA REPORTING AWARD AMOUNT: $ 105,806.00 EMPA QUARTERLY CLAIM CUM. FUNDS EXPENDED REMAINING BALANCE QUARTER 1 $0.00 $105,806.00 QUARTER 2 $0.00 $105,806.00 QUARTER 3 $0.00 $105,806.00 QUARTER 4 $0.00 $105,806.00 TOTAL EMPA CLAIMS $0.00 MATCH REPORTING REQUIRED MATCH AMOUNT: $ EMPA LOCAL General Revenue LOCAL (Other) OTHER (Non -Federal) QUARTER 1 QUARTER 2 QUARTER 3 QUARTER 4 TOTAL $0.00 $0.00 r $0.00 $0.00 EMPG TOTAL MATCH 1 $0.00 "By signing this report, /certify to the best of my knowledge and belief that the reportis 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. I 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 True 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)." SIGNATURE AUTHORIZED REPRESENTATIVE PRINT® NAM E TITLE DATE 65