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Santa Ana Urban Areas Security Initiative/ <br />Public Safety Interoperable Communications Grant <br />Reimbursement Request for Grant Expenditures <br />Mail Reimbursement Request to: <br />❑ This is the final reimbursement request <br />Agency / City Requesting Reimbursement <br />Total Amount Requested: $ <br />Attach copies of supporting 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 />assurances. <br />• All attached invoices for items and /or services have been received in full. <br />Printed Name <br />Title <br />Mailing Address <br />City, State, Zip Code <br />Signature <br />(Please sign in blue ink.) <br />• Authorized Agent <br />Number <br />E -Mail Address <br />Fax Number <br />Date <br />For Santa Ana UASUPSIC Grant Coordinator Use Only <br />Approved for <br />Date: <br />Processing: <br />Request Tracking Number: <br />Account #: <br />Grant: <br />PSIC <br />Grant <br />Project: <br />Solution <br />Year: <br />Area: <br />Special Instructions / <br />Comments <br />35 <br />