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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: ^ This is the final reimbursement request <br />^ FY07PSIC <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 ReimbursementT <br />Total Amount Requested: <br />ttach cople3 Of 3uDDOrtlna invninnel <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 A:?ent <br />/ ~ P,rmted ame <br />Title " 1 ~ ~~~i 1 r~1.~rC ~ ~j/F/"rT Fi"~ €L <br />Mtailmg Address ,~--- <br />City, State, ~p Code <br />/~ ~ <br />`''W GMw~ <br />Signature <br />(Please sign in blue ink.) <br />~'~5- ~~'i-55'~1~ <br />Phone Number <br />RA ti~ v. 4 MG~'~C:tr) . `l ~..~?$ - IJ A "•~ bii L r)f'. <br />G!~ ~ cJ $ <br />E-Mail Address <br />Fax Number <br />~ ~ 6/c ~ <br />Dat <br />For Anaheim/Santa Ana UASI Grant Coordinator Use <br />Approved for <br />Request Tracking Number: <br />Grant: PSIC Grant <br />Year: Project: <br />Special Instructions / <br />Comments <br />Account #: <br />Solution <br />Area: <br />Date: <br />37 <br />