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FY 2022 — 2023 EMPA AGREEMENT <br />ATTACHMENT F -REPORTING FORMS <br />2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT PROGRAM <br />DIVISION FORM 213- DETAIL OF CLAIMS <br />SALARIES AND FRINGE BENEFITS <br />Pay Period: From: To: <br />Sub -Recipient Name: <br />Incurred Date Range: <br />Claim #: <br />DOES THIS CLAIM FOR REIMBURSMENT INCLUDE EXPENSES FOR ANY INCENTIVES OR SPECIAL PAY? Note: If this claim includes <br />incentives or special pay, please provide FDEM with the written established policy for support. <br />T V <br />J C O d <br />U a <br />N C 1= <br />U <br />> <br />3 v <br />m O Q •`- <br />EM Funded staff Name a LL <br />O <br />O- iv o v a f0 c <br />w "c = c 3 c Q m <br />$ 15,000.00 <br />SubTotals $ 15,000.00 $ <br />Total Cost Charged to the Grant $ 15,000.00 <br />"By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and <br />accurate, and the expenditures, disbursements and cash receipts are for the pruposes and objectives set forth in the <br />terms and conditions of the Federal award. I am aware that any false, fictitious, orfradulent information, or the <br />ommission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false <br />statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801- <br />3812)." <br />SIGNATURE: <br />AUTHORIZED REPRESENTATIVE <br />PRINTED NAME: <br />TITLE: <br />DATE: <br />55 <br />273 <br />