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CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES (Cal OES) <br />ALN <br />through <br />(Beginning Performance Period Date)(Ending Performance Period Date) <br />AUTHORIZED AGENT <br />NOTE: Unauthorized alterations will delay the approval of this request. <br />County of Orange EMPG 97.042 <br />2022-0005 <br />Supporting Information for Application, Modification, or Request for Federal Funds <br />This claim is for costs incurred within the grant performance period. <br />This request is for a/an:Modification July 1, 2022 June 30, 2024 <br />Steven A. Mendoza Acting City Manager <br />(Request #)(Amount This Request) <br />Under Penalty of Perjury, I certify that: <br />I am the duly authorized officer of the claimant herein. This claim is true, correct, and all expenditures were made in accordance with applicable laws, rules, regulations, and <br />grant conditions and assurances. <br />Statement of Certification - Authorized Agent <br />By signing this report, I certify, to the best of my knowledge and belief, that the report is true, complete, and accurate, and that the expenditures, disbursements, and cash <br />receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the <br />omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 <br />and Title 31, Sections 3729–3730 and 3801–3812). <br />Signature of Authorized Agent Date <br />Printed Name of Authorized Agent Title of Authorized Agent <br />September 20, 2023 <br />FY 2022 EMPG FMFW (Macro) v.22 26 of 26 AA Approval