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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 3A - Quarterly Match <br />SUB -RECIPIENT: <br />QUARTERLY REPORTING PERIOD: July 1 -Sept. 30 <br />CLAIM # <br />1. Federal funds provided under the 2022-2023 EMPG agreement shall be matched bythe Sub -Recipient (dollar -for -dollar) totaling the award amount. Each quarter <br />the Sub -Recipient must identify the non-federal match amounton the Quarterly Match Form 3A <br />2. If the EMPG funds are being matched with 2022-2023 EMPAclaimed expenditures, no additional back-up/supporting documentation is required to be submitted <br />with this form. <br />3. Ifthe 2022-2023 EMPG award exceeds the 2022-2023 EMPAaward, or if the Sub -Recipient is not using EMPAclaimed expenditures to fulfill the EMPG match <br />requirement, appropriate back-up/supporting documentation must accompanythis form to support fulfillment of the required match (i.e. invoices, receipts, paystubs, <br />earning statements, cancelled checks, credit card and bank statements, etc. ). <br />EMPG REPORTING <br />AWARD AMOUNT: <br />$ 105,806.00 <br />EMPG QUARTERLY CLAIM <br />CUM. FUNDS EXPENDED <br />REMAINING BALANCE <br />QUARTER 1 <br />$0.00 <br />$0.00 <br />QUARTER 2 <br />$0.00 <br />$0.00 <br />QUARTER 3 <br />$0.00 <br />$0.00 <br />QUARTER 4 <br />$0.00 <br />$0.00 <br />TOTAL EMPG CLAIMS $0.00 <br />EMPA REPORTING <br />AWARD AMOUNT: <br />$ 105,806.00 <br />EMPA QUARTERLY CLAIM <br />CUM. FUNDS EXPENDED <br />REMAINING BALANCE <br />QUARTER 1 <br />$0.00 <br />$105,806.00 <br />QUARTER 2 <br />$0.00 <br />$105,806.00 <br />QUARTER 3 <br />$0.00 <br />$105,806.00 <br />QUARTER 4 <br />$0.00 <br />$105,806.00 <br />TOTAL EMPA CLAIMS $0.00 <br />MATCH REPORTING REQUIRED MATCH AMOUNT: $ <br />EMPA LOCAL (General Revenue) LOCAL (Other) OTHER (Non -Federal) <br />QUARTER 1 <br />QUARTER 2 <br />QUARTER 3 <br />QUARTER 4 <br />TOTALI $0.00 SQ00 r 50 00 $0.00 <br />EMPG TOTAL MATCH $0.00 <br />"By signing this report, 1 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 <br />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 anymatenal <br />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 <br />3729-3730 and 3801-3812)." <br />SIGNATURE, <br />PRINTED NAM E <br />TITLE <br />DATE <br />AUTHORIZED REPRESENTATIVE <br />X" <br />197 <br />