20A - APPR ADJ HOMELAND SEC GRANT

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CITY OF LOS ANGELES URBAN AREA SECURITY INITIATIVE GRANT Reimbursement Request Form Return Reimbursement Requests to: Rachel Tkatch Mayor's Office of Homeland Security and Public Safety 200 N. Spring 5t., Room #M-175A Los Angeles, CA 90012 Phone: 213.978.0701 Fax: 213.978.0718 rachel.tkatchCa~lacity.org UASI FY03 Part 1 ^ UASI FY04 ^ UASI FY03 Part 2 ^ UA51 FY05 ^ Core City: Requesting Agency: Reimbursement Period: to Prepared By: Phone No.: Please mark this box to indicate final Line: request for reimbursement ^ Authorized Previously Current Cumulative Type of Expenditure Balance Total Amount Request Request Request E ui ment ,,, ~ `. ~~% Exercise '~ ~ t` ``~"~3" Trainin k, t, ~'~ ~ ,;; ~~ ~ ' Plannin ~? #„' k~4~' O eration l Activities ~; ' ~ ~~ ~` ~ ~ a . ' ~ ,;,~ , Mana ement & Admin K acr-. ~ ;~ ~ % ~ s -- ,,. ~~, ~;. ;~ Total ~ ~'`_~' ~ ~' ~ - This reimbursement claim is in all respects true, correct, and all expenditures were made in accordance with applicable laws, rules, regulations, and grant conditions and assurances. In addition, this claim is for cost incurred within the Grant Performance Period. Also, a!1 supporting documentation related to these expenditures will be retained in accordance with grant guidelines. Authorized Department Approval: Please Remit Payment to: Print Name Title Signature Daie Phone No. (extension) Fax No. Name Address City State Zip Reference No. E-mail Address To be completed by HSPS Accounting Department DHS/OES Reimbursement Request By: _ ._ Transaction ID:_ Date: DHSlOES Reimbursement Received:.- Cash Receipt No.____ JV No. - Transfer to Depart JV No. 20A-69