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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: July 1 through Sept. 30, 2022 <br />Please use separate Division Forth 2A - Detail of Claims per allocation category. Please protide FEMA AEL numbers for EQUIPMENT expenditures ONLY. <br />Please protide a budget revision to the Division along with this forth, if expenses being claimed are not allocated on the most recently approved budget. <br />Please include the Costs Incurred Date Range in the applicable cell above. This is usually the quarterly period; however, a Sub -Recipient may incorporate a larger date <br />range to include a forgotten claim for reimbursement for a payment made the previous 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:1 PLANNING <br />DATE OF <br />PAYMENT PAYMENT PURCHASE <br /># VENDOR DESCRIPTION OF SERVICE OR EXPENSE FOR SERVICE REFERENCE # AMOUNT <br />OR EXPENSE (CHECK#, FO, CC#, JT) <br />Include full date <br />FEMA AEL# <br />(WA If equipment was not <br />purchased) <br />1 <br />2 <br />3 <br />4 <br />5 <br />8 <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 bestofmy knowledge and beliefthat the report is true, complete, and accurate, and the expenditures, disb ursements and cash receipts are for <br />the purposes and objectives set rorth in the terms and conditions ofthe Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any m aterial <br />Fact, maysubject me to criminal, civil or administrative penalties forfraud, false statements, false claims or otherwise. (US. Code Title 18, Section 1001 and Title 31, Sections <br />3729-3730 and 3801-3812)." <br />SIGNATURE: <br />AUTHORIZED REPRESENTATIVE <br />PRINTED NAME: <br />TITLE: <br />63 <br />195 <br />