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<br />Attachment A <br /> <br /> Urban Areas Security Initiative <br /> Reimbursement Request for Grant Expenditures <br /> Award # <br />Mail Reimbursement ReQuest to: Applicant: <br /> Core City / Transit Agency <br />Governor's Office of Emergency Services OES ID #: <br />Grant Payments Unit <br />Post Office Box 419023 Please mark this box to indicate a change in <br />Rancho Cordova, CA 95741-9023 the Authorized Agent Mailing Address <br /> belowD <br /> Total <br /> Expenditures <br /> Project # Solution Area Expenditure Period (from/to dates) for the <br /> Expenditure <br /> Period <br /> . <br /> Grand Total <br />Under penalty of perjury, I certify that: <br />. I am the duly authorized officer of the claimant herein. <br />. This claim is in all respects true, correct, and all expenditures were made in accordance with <br /> applicable laws, rules, regulations and grant conditions and assurances. <br />Authorized Agent (per Governing Body Resolution) <br />Printed Name Phone Number <br />Title E-Mail Address <br />Mailing Address Fax No. <br />City, State, Zip Code <br />Signature Date <br />FY04 Urban Areas Security Initiative Page 78 <br />