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40 <br />El <br />40 <br />40 <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: <br />ADDRESS: <br />PAYMFN'I'NO:.._._,_..­_ <br />DEC NO: <br />PA ID NO: <br />IX,'A AGREEMENT NO; <br />TOTAL CURRENT REQUEST S — <br />I certify that it) the best of my knowledge and belief the &bve acctxmitswe correct and that alt dblivirvenicittitwere made in accordance with all <br />corxV:ons of the IWA agreement and payment is dw and has rKyt been pmvi(maly requaW for dme affoutim <br />SUBGRANTEE SIGNATURE <br />NAME AND TIT <br />DATE: <br />TO BE COMPLETED BY DEPARTMENT OF COMMUNITY AFFAIRS (DCA) <br />APPROVED FOR PAYMENT S — I <br />ADMINISTRATIVE COST $ GOVERNOR'S AUTHORIZED REPRESENTATIVE <br />TOTAL PAYMENT $ DATE I <br />099 <br />DSR <br />DCA USE ONLY <br />1,11GIBLE <br />PREVIOUS <br />CURRENT <br />AMOUNT <br />PAYMEN­IS <br />REQUEST <br />APPROVED <br />FOR PAYh4EN'T <br />USRJI <br />CATEGORY, <br />% COMPLETE <br />XCOMI <br />Ds" <br />CAT <br />%COMPLFTE <br />DSR4_ <br />DS <br />CATEGORY_- <br />% COMPLETE <br />DSR# — <br />CATEGORY-- <br />% COMPLETE <br />DSR#_._ <br />CATEGORY__.____ <br />% COMPLETE—M <br />TOTAL CURRENT REQUEST S — <br />I certify that it) the best of my knowledge and belief the &bve acctxmitswe correct and that alt dblivirvenicittitwere made in accordance with all <br />corxV:ons of the IWA agreement and payment is dw and has rKyt been pmvi(maly requaW for dme affoutim <br />SUBGRANTEE SIGNATURE <br />NAME AND TIT <br />DATE: <br />TO BE COMPLETED BY DEPARTMENT OF COMMUNITY AFFAIRS (DCA) <br />APPROVED FOR PAYMENT S — I <br />ADMINISTRATIVE COST $ GOVERNOR'S AUTHORIZED REPRESENTATIVE <br />TOTAL PAYMENT $ DATE I <br />099 <br />