Laserfiche WebLink
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 />^ FY07 PSIC <br />Santa Ana Police Department <br />Attn: Sgt. Enrique Esparza, Grant Coordinator <br />60 Civic Center Plaza <br />P.O. Box 1981 <br />Santa Ana, CA 92702 <br />Agency /City Requesting Reimbursement <br />Total Amount Requested: $ <br />Attach co ies of su ortin 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 />• Authorized Agent <br />Printed Name <br />Title <br />Mailing Address <br />City, State, Zip Code <br />Signature <br />(Please sign in blue ink.) <br />Phone Number <br />E-Mail Address <br />Fax Number <br />Date <br />For Anaheim/Santa Ana UASI Grant Coordinator Use Onl <br />Approved for <br />Date: <br />Processin <br />Request Tracking Number: Account #: <br />Grant: PSIC Grant Project: Solution <br /> Year• Area: <br />Special Instructions / <br />Comments <br />37 <br />