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• <br />11 <br />ATTACHMENT D <br />FLORIDA DEPARTMENT OF COMMUNITY AFFAIRS <br />DIVISION OF EMERGENCY MANAGEMENT <br />Request for Advance or Reimbursement for Public Assistance Funds <br />SUBGRANTEE NAME: DEC NO: <br />ADDRESS: PA ID NO: <br />PAYMENT NO: DCA AGREEMENT NO: <br />TOTAL CURRENT REQUEST $ <br />1 certify that to the best of my knowledge and belief the above accounts arc correct and that all disbursements were made in accordance with all <br />conditions or die DCA agreement and payment is due and has not been previously requested for these amounts. <br />SUBGRANTEE SIGNATURE <br />NAMEAND <br />DATE: <br />TO DE COMPLETED BY DEPARTMERr OF COMMUNITY AFFAIRS (DCA) <br />APPROVED FOR PAYMENT $ <br />ADMINISTRATIVE COST $ GOVERNOR'S AUTHORIZED REPRESENTATIVE <br />"TOTAL PAYMENT $ <br />DATE, <br />D-1 <br />DSR <br />DCA USE ONLY <br />ELIGIBLE <br />PREVIOUS <br />CURRENT <br />AMOUNT <br />PAYMENTS <br />REQUEST <br />APPROVED <br />FOR PAYMENT <br />COMMENTS <br />DSR# <br />CATEGORY <br />%COMPLETE <br />DSRII <br />CATEGORY <br />COMPLETE <br />DSR1d <br />CATEGORY <br />%COMPLETE <br />DS R11 <br />CATEGORY <br />%COhTPLETE <br />DSR9 <br />CATEGORY <br />%COMPI.ETE <br />TOTAL CURRENT REQUEST $ <br />1 certify that to the best of my knowledge and belief the above accounts arc correct and that all disbursements were made in accordance with all <br />conditions or die DCA agreement and payment is due and has not been previously requested for these amounts. <br />SUBGRANTEE SIGNATURE <br />NAMEAND <br />DATE: <br />TO DE COMPLETED BY DEPARTMERr OF COMMUNITY AFFAIRS (DCA) <br />APPROVED FOR PAYMENT $ <br />ADMINISTRATIVE COST $ GOVERNOR'S AUTHORIZED REPRESENTATIVE <br />"TOTAL PAYMENT $ <br />DATE, <br />D-1 <br />