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FY 2022 - 2023 EMPA AGREEMENT <br />ATTACHMENT F -REPORTING FORMS <br />FLORIDA DIVISION OF EMERGENCY MANAGEMENT <br />2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA <br />DIVISION FORM 2A - DETAIL OF CLAIMS <br />RECIPIENT: <br />INCURRED DATE RANGE: Example: July 1 through November 5, 2022 <br />Please use separate Division Form 2A -Detail of Claims per allocation category. Please add additional pages or lines as needed for each allocation category. <br />Please provide FEMAAEL numbers for EQUIPMENT eprenditures only. <br />Please protide a budget recision along with this form, 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 usuallythe quarterlypenod; however, a recipient may incorporate a larger <br />date range to include a forgotten claim for reimbursement for a payment made the previous quarter (within the period ofagreement). This allowance does not <br />circumventthe four (4) required quarterly reporting forms submissions. <br />ALLOCATION CATEGORIES <br />PLEASE SELECT FROM THE LIST BELOW <br />CATEGORY: ORGANIZATION <br /># VENDOR <br />DESCRIPTION OF OR <br />EXPENSE <br />EXPEN <br />DATE OF <br />SERVICE OR PAYM ENT FOR <br />EXPENSE <br />(Include ful date) <br />PAYMENT <br />REFERENCE <br />(CHECK#,PO#, <br />JT#, etc.) <br />PURCHASE <br />AMOUNT <br />Equipment FEMA AE117 (N/Aif <br />equipmentwas notpurchased) <br />1 Ex: Electric Company <br />Monthly Utilities for July 2022 <br />8/5/22 <br />CK# 1001 <br />$ 300.00 <br />N/A <br />2 <br />3 <br />4 <br />5 <br />6 <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 />21 <br />22 <br />23 <br />24 <br />25 <br />TOTAL $ <br />300.00 <br />ey ag,Fing mist report, 1 cernry ""I lest or my Knowledge and owner roar me report is true, complete, accurate and the Fx*enditure; disbursements and Cash <br />receipts are for the purposes and objectives set forth in the conditions of the 2022-2023 EM PA agreement. <br />SIGNATURE: <br />AUTHORIZED REPRESENTATIVE <br />PRINTED NAME: <br />DATE: <br />54 <br />272 <br />