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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 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 />termination date of the agreement. The 2022.2023 period of agreement ends on June 30, 2023. DIVISION Form 5 is due by <br />August 30, 2023. <br />RECIPIENT: AGREEMENT#: <br />POINT OF CONTACT: EMPAAWARD AMOUNT: <br />PHONE/EMAIL: UNCLAIMED BALANCE: <br />ALLOCATION CATEGORIES ALLOCATIONS <br />1. PLANNING $ - <br />2. ORGANIZATION <br />3. TRAINING <br />4. EXERCISE <br />5. EQUIPMENr <br />6. MANAGEMENT AND ADMIN. <br />$ <br />AWARD AMOUNT: $ <br />(LESS ADVANCED FUNDS) <br />(LESS REIMBURSEMENTS) $ <br />UNCLAIMED BALANCE OF AWARD $ <br />R IMBURSOVENTS RECEIVED BY THE RECIPIENT <br />(Include any advanced funds and final requested payment) <br />DATE AMOUNT <br />In accordance with Rule 27P-19.011, Florida Adrrinistrative Code, base grants shall be retched at an amount either equal to the average of the <br />previous three years' level of county general revenue funding of the County Erergency Management Agency or the level of funding for the County <br />Emergency Management Agency for the last fiscal year, whichever is lower. Required with this fora} the county needs to provide a copy of the <br />current EM local budget (general revenue) and general ledger expenditure report as of 6/30/2023. <br />AVERAGEOF <br />2022-2023 EM LOCAL <br />RECIPIENT <br />2022-2023 <br />2021-20202020-2019 <br />2019-2018 <br />PREVIOUS <br />GENERAL REVENUE <br />LOCAL <br />LOCAL <br />LOCAL <br />LOCAL <br />3 YEARS <br />EXPENDITURES <br />E rn ple: FL County <br />SIGNATURE REQUIRED <br />Bysfgning this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the eupendltures, <br />disbursementsand cash receiptsare forthe purposesand objectivesset forth in the conditions of the 2022.2023 EMPA agreement. <br />SIGNATURE AND DATE <br />AUTHORIZED REPRESENTATIVE <br />PRINTED NAMEAND TITLE <br />Refund and/or final interest checks are due no later than ninety (90) days after the expiration of the agreement. Please submit this <br />form and supporting documentation to: Florida Division of Emergency Management, 2555 Shumard Oak Blvd., Tallahassee, FL 32399, <br />Attn: (Division Grant Manager) <br />BELOW TO BE COM PLErED BY DIVISION <br />SIGNATUREAND DATE <br />DIVISION GRAM MANAGER <br />SIGNATURE AND DATE <br />DIVISION PROGRAMMATIC REVIEWER <br />58 <br />276 <br />