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FY 2022 - 2023 EMPG AGREEMENT ATTACHMENT H REPORTING FORMS STATE OF FLOHIUA INDIAN RIVER COUNTY THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF THE ORIGINAL ON FILE IN THIS OFFICE. ,!fh JEFFREY R. SA11TH. CLERK FLORIDA DIVISION OF EMERGENCY MANAGEMENT " 2022.2023 EMERGENCY MANAGEMENT PERFORMANCE GRANT PROGRAM - BASE GRANT DIVISION FORM 5 - CLOSE-OUT REPORT Division FORM 5 - CLOSEOUT REPORT shall be completed and submitted to the Division no later than sixty (60) days after the period of performance ends. The 2022-2023 period of performance ends on September 30, 2023. Division FORM 5 is due by October 30, 2023. SUB -RECIPIENT: POINT OF CONTACT: PHONEJEMAIL: ALLOCATION CATEGORIES EXPENDITURES 1. PLANWINC $ - 2. ORGANIZATION $ - 3. EQUPIvt3NT $ _ 4. TRAINING $ _ 5. EXERCISE $ - 6. MANAGEMWT AND ADMN. $ - AWARD AMOUNT $ (LESS ADVANCED FUNDS) $ (LESS REIMBURSEMENTS) $ UNCLAIMED BALANCE OF AWARD $ AGREEMENT #: EMPG AWARD AMOUNT: UNCLAIMED BALANCE: R9vEU2SEM3NTS RECEIVED BY THE SLII& FEJT (Include any advanced funds and final requested payment) DATE AMOUNT $ Federal funds provided under the 2022-2023 EMPG agreement shall be matched by the Sub -Recipient (dollar -for -dollar) with non-federal funds. If the EMPG award is being matched with EMPA, no additional back-up/supporting documentation is needed to be provided to the Division If the EMPG award exceeds the EMPA award or using local funds for match, the appropriate back-up/supporting documentation for the match fulfillment shall be provided with this form (i.e. invoices, cancelled checks, earning statements, payroll registries, with amounts clearly identified). EMPA LOCAL General Revenue LOCAL Other OTHER Non -Federal TOTAL MATCH SIGNATURE REQUIRED "Bysigning thisreport, I certify to the best of myknowledge and belief that the report is true, complete, and accurate, end the expenditure; dlsbursementsond cash recelptsare for the purposesand objectivesset forth in the termsand conditions of the Federal award. Ism aware that anyfalse, l itious. or fraudulent information, or the omission of any material fad, may subject me to criminal, civil or administrative penalties for fraud, N/se statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sect/ons3729-3730 and 3801-3812)." SIGNATURE AND DATE: AUTHORIZED REPRESENTATIVE PRINTED NAM AND TITLE: Refund and/or final interest checks are due no later than ninety (90) days after the expiration of the Agreement. Make checks payable to: Cashier, Florida Division of Emergency Management Mail to: Florida Division of Emergency Management, 2555 Shumard Oak Blvd., Tallahassee, Florida 32399-2100, Attn: (Division Grant Manager) BELOW TO BE COMPLETED BY FDEM: SIGNATURE AND DATE: Division Grant Manager SIGNATURE AND DATE: Division Programmatic Reviewer 67