Sample "Reimbursment Request Form - Uasi Grant Program" - Arizona

Reimbursment Request Form - Uasi Grant Program is a legal document that was released by the Arizona Department of Homeland Security - a government authority operating within Arizona.

Form Details:

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Download Sample "Reimbursment Request Form - Uasi Grant Program" - Arizona

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Arizona Department of Homeland Security
FFY 2014 UASI Grant Program
Subgrantee Name and Address
Reimbursment Request Form
State of Confusion
Contract Number
Name
123456-01
Date cannot be prior to
the beginning of the
Contact Person
Hernan Cortez
Reporting Period From:
period of performance.
Address
Telephone
999-867-5309
123 Lost Way
Reporting Period To:
City
Lost City, AK
Zip
99215
E-Mail
hcortez@lostcity.org
10/1/2015
9/30/2016
Funds Begin
Funds End
Date cannot be after the
Major Budget Category / Line Item Detail
end of the period of
Contract Budget
Current Period
Year to Date
Budget Remaining
performance
$500.00
$500.00
$500.00
Planning
$1,000.00
Enter amount you are
$1,000.00
$1,000.00
$1,000.00
Organization
$2,000.00
seeking on this
$1,500.00
$1,500.00
$1,500.00
reimbursement.
06CP-01-MOBL - Mobile Radio Equipment 2@ $1500.00
$3,000.00
$2,000.00
$2,000.00
$2,000.00
Training
$4,000.00
Enter total amount
reimbursed to date
$2,500.00
$2,500.00
$2,500.00
Exercise
$5,000.00
(which includes any
previous reductions)
PLUS the amount of this
request.
Total Costs
$15,000.00
$7,500.00
$7,500.00
$7,500.00
Contractor Certification: I certify that this report has been examined by me, and to the best of my knowledge and belief, the reported expenditures are valid, based upon our office accounting records (books of account) and are consistent with the terms of the contract.
It is understood that contract payments are calculated by the Arizona Department of Homeland Security based upon contract terms.
Preparer's Signature
Name/Title
Phone Number
Stakeholder Authorizing Signature
Name/Title
Phone Number
Any Questions Please Contact:
Kevin Mancino
Original Submission
(602) 542-1716
Revised Submission
Kmancino@azdohs.gov
Final Submission
Arizona Department of Homeland Security
FFY 2014 UASI Grant Program
Subgrantee Name and Address
Reimbursment Request Form
State of Confusion
Contract Number
Name
123456-01
Date cannot be prior to
the beginning of the
Contact Person
Hernan Cortez
Reporting Period From:
period of performance.
Address
Telephone
999-867-5309
123 Lost Way
Reporting Period To:
City
Lost City, AK
Zip
99215
E-Mail
hcortez@lostcity.org
10/1/2015
9/30/2016
Funds Begin
Funds End
Date cannot be after the
Major Budget Category / Line Item Detail
end of the period of
Contract Budget
Current Period
Year to Date
Budget Remaining
performance
$500.00
$500.00
$500.00
Planning
$1,000.00
Enter amount you are
$1,000.00
$1,000.00
$1,000.00
Organization
$2,000.00
seeking on this
$1,500.00
$1,500.00
$1,500.00
reimbursement.
06CP-01-MOBL - Mobile Radio Equipment 2@ $1500.00
$3,000.00
$2,000.00
$2,000.00
$2,000.00
Training
$4,000.00
Enter total amount
reimbursed to date
$2,500.00
$2,500.00
$2,500.00
Exercise
$5,000.00
(which includes any
previous reductions)
PLUS the amount of this
request.
Total Costs
$15,000.00
$7,500.00
$7,500.00
$7,500.00
Contractor Certification: I certify that this report has been examined by me, and to the best of my knowledge and belief, the reported expenditures are valid, based upon our office accounting records (books of account) and are consistent with the terms of the contract.
It is understood that contract payments are calculated by the Arizona Department of Homeland Security based upon contract terms.
Preparer's Signature
Name/Title
Phone Number
Stakeholder Authorizing Signature
Name/Title
Phone Number
Any Questions Please Contact:
Kevin Mancino
Original Submission
(602) 542-1716
Revised Submission
Kmancino@azdohs.gov
Final Submission