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FY 2022 - 2023 EMPA AGREEMENT <br />ATTACHMENT F-REPORl1NG FORMS <br />FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA <br />DIVISION FORM 5 -CLOSE-OUT REPORT <br />DIVISION FORM 5 - CLOSEOUT REPORT shall be completed and submitted to the Division no later than sixty (60) days after the <br />termination date of the agreement. The 2022-2023 period of agreement ends on June 30, 2023. DIVISION Form 5 is due by <br />August30,2023. <br />RECIPIENT: AGREEMENTM <br />POINT OF CONTACT: EMPAAWARD AMOUNT: <br />PHONE/EMAIL: UNCLAIMED BALANCE: <br />ALLOCATION CATEGORIES ALLOCATIONS <br />1. PLANING $ <br />2. ORGANIZATION <br />3. TRAINING <br />4. EXERCISE <br />5. EOUFIVENT <br />6. MARAC43A'ENT AND ADM. <br />$ <br />AWARD AMOUNT: $ <br />(LESS ADVANCED FUNDS) <br />(LESS REIMBURSEMENTS) ,$ <br />UNCLAIMED BALANCE OF AWARD $ <br />(Include any advanced funds and final requested payment) <br />DATE AMOUNT <br />S <br />In accordance w ith Rule 27819.011, Florida Admnis"We Code, base grants shall be matched at an amount either equal to the average of the <br />previous three years' level of county general revenue funding of the County Eriergency Management Agency or the level of funding for the County <br />Emergency Management Agency for the last fiscal year, w hichever m low er. Required w ith this form the county needs to provide a copy of the <br />current EM local budget (general revenue) and general ledger expenditure report as of 6130/2023. <br />2022-2023 <br />2021-2020 <br />2020-2019 <br />2019-2018 <br />AVERAGEOF <br />2022-2023 EMLOCAL <br />�I�T <br />LOCAL <br />LOCAL <br />LOCAL <br />LOCAL <br />PRFV IKKIS <br />GENERAL REVENUE <br />3 YEARS <br />EXPENDITURES <br />Eenple: FL County <br />SIGNATURE REQUIRED <br />By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, <br />disbursements and cash receiptsare for the purposesand objectives set forth in the conditions of the 2022-2023 EUPA agreement. <br />SONATIJREAPD DATE <br />AUTHORIZED REDMENTATIVE <br />PIWTED NAME AND TITLE <br />Refund and/or final Interest checks are due no later than ninety (90) days after the expiration of the agreement. Please subm It this <br />form and supporting documentation to: Florida Division of Emergency Management, 2555 Shumard Oak Blvd., Tallahassee, FL 32399, <br />Attn: (Division Grant Manager) <br />BROW TO BE COMPLBED BY DIVISION <br />SIGNATUREAND DATE <br />DIVISION GRAM MANAGER <br />SIGNATURE AND DATE <br />DIVISION PROGRAMMATIC REVIEWER <br />J I A I t OF FLORIDA <br />INDIAN RIVER COUNTY <br />THIS IS TO CERTIFY THAT THIS 18 A TRUE AND CORRECT <br />58 COPY OF THE ORIGINAL ON FILE IN THIS OFFICE. <br />JEFFREY R. SMITH, CLERK <br />BY D.C. <br />DATE <br />