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Department of Health <br /> EMS GRANT PROGRAM EXPENDITURE REPORT <br /> Name of Grantee: Grant ID Code: <br /> Time Period Covered: Beginning Date: 01101/2002 Ending Date: 01101/2002 <br /> Earned Interest: Amount $ ; as of _ <br /> Day Month Year <br /> Final Report Check one): ❑Yes ❑ No <br /> Major Line Items TOTAL <br /> Approved Budget Expenditure by Major Line Item(s) $ <br /> TOTAL BUDGETED EXPENDITURES $ <br /> Actual Expenditure to Date by Major Line Item(s) $ <br /> TOTAL EXPENDITURES $ <br /> BALANCE (Budgeted Less Actual Expenditures) $ <br /> Include with the progress notes an explanation of how project personnel, equipment, and any problems or barriers <br /> may impact on the grant progress. <br /> I certify the above reports are true and correct. Expenditures were made only for items allowed by <br /> the above referenced grant. <br /> Signature of Authorized Official Date <br /> DH Form 1684A, Rev. June 2002 <br /> 7 <br />