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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 - BASE GRANT <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 />period of performance ends. The 2022-2023 period of performance ends on September 30, 2023. Division FORM 5 is due by <br />October 30, 2023. <br />SUB -RECIPIENT: <br />POINT OF CONTACT: <br />P HONEIEMAI L: <br />ALLOCATION CATEGORIES <br />EXPBmTTURES <br />1. PLANKING <br />$ _ <br />2. ORGANIZATION <br />$ - <br />3. EQUIPMENT <br />$ - <br />4. TRAINING <br />$ - <br />5. EXERCISE <br />$ - <br />6. MANAGEMENT AND ADMIN. <br />$ - <br />AWARD AMOUNT $ <br />(LESS ADVANCED FUNDS) $ <br />(LESS REIMBURSEMENTS) $ <br />UNCLAIMED BALANCE OF AWARD $ <br />AGREEMENT <br />EMPG AWARD AMOUNT: $ <br />UNCLAIMED BALANCE: $ <br />(include any advanced funds and final requested payment) <br />DATE AMOUdT <br />Federal funds prodded under the 2022-2023 EMPG agreement shall be matched by the Sub -Recipient (dollar -for -dollar) with non-federal <br />funds. If the EMPG award is being matched with EMPA, no additional back-up/supporting documentation is needed to be prodded to the <br />Division. If the EMPG award exceeds the EMPA award or using local funds for match, the appropriate back-up/supporting <br />documentation for the match fulfillment shall be provided with this form (i.e. invoices, cancelled checks, earning statements, payroll <br />registries, with amounts clearly identified). <br />EMPA LOCAL General Revenue er LOCAL OthOTHER Non -Federal <br />TOTAL MATCH <br />SIGNATURE REQUIRED <br />"Bysigning thisreport, I certify to the best ofmy knowledge and belief that the report istrue, complete, and accurate, and the expenditure; <br />disbursem ents a nd cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. lam aware that <br />any false, fictitious or fraudulent information, or the omission of anymaterial fact, may subject me to criminal, civil or administrative penalties <br />for fraud, false statement; false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)." <br />SIGNATURE AND DATE: <br />AUTHORIZED REPRESENTATIVE <br />PRINTED NAME AND TITLE: <br />Refund and/or final interest checks are due no later than ninety (90) days after the expiration of the Agreement. <br />Make checks payable to: Cashier, Florida Division of Emergency Management <br />Mail to: Florida Division of Emergency Management, 2555 Shumard Oak Blvd., Tallahassee, Florida 32399-2100, Attn: (Division Grant Manager) <br />BELOW TO BE COMPLETED BY FDEM: <br />SIGNATURE AND DATE: <br />Division Grant Manager <br />SIGNATURE AND DATE: <br />Division Programmatic Reviewer <br />ZA <br />199 <br />