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Anaheim/Santa Ana Urban Areas Security Initiative <br />Reimbursement Request for Grant Expenditures <br />Mail Reimbursement Request to: ❑ This is the final reimbursement request <br />❑ FY06 UASI <br />❑ FY07 UASI <br />Anaheim Police Department <br />Santa Ana Police Department <br />East Station — Homeland Security Bureau <br />Attn: Sgt. Enrique Esparza, Grant Coordinator <br />Attn: Lisa Navarro, Grant Coordinator <br />60 Civic Center Plaza <br />425 S. Harbor Blvd. <br />P.O. Box 1981 <br />Anaheim, CA 92805 <br />Santa Ana, CA 92702 <br />Agency /City Requesting Reimbursement <br />Total Amount Requested: <br />$ <br />Attach co ies of sipporting invoices <br />Under penalty of perjury, I certify that: <br />• I am an authorized officer of the claimant herein. <br />• This claim is in all respects true, correct, and all expenditures were made in <br />accordance with applicable laws, rules, regulations and grant conditions and <br />Title <br />assurances. <br />All attached invoices for items and/or services have been received in full. <br />Authorized Agent <br />Name Phone Number <br />E-Mail Address <br />Mailing Address Fax Number <br />City, State, Zip Code <br />Signature <br />(Please sign in blue ink.) <br />nta Ana UASI Grant Coordinator Use Onlor <br />Dte: <br />:king <br />Number: <br />Account N: <br />I <br />W <br />Grant <br />Project: <br />Solution <br />Year:nstructions <br />/ <br />Comments <br />42 <br />