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• <br />EXHIBIT D <br />Anaheim and Santa Ana Urban Areas Security Initiative <br />Reimbursement Request for Grant Expenditures <br />Mail Reimbursement Request To: ~ This is the final reimbursement request. <br />.FY09'UASI Grant`Program :x ~ ,~. ~'FY10 UAS) .Grant Program { <br />` t i ,yam •~ ~ F , ~. '~ <br />Sgt. Enrique Esparza, Grant Coordinator Cindy Nickel, Grant Fiscal Coordinator <br />Santa Ana Police Department Anaheim Police Department <br />Homeland Security Division East Station-Homeland Security Bureau <br />60 Civic Center Plaza-P.O. Box 1981 425 S. Harbor Boulevard <br />Santa Ana, CA 92702 Anaheim, CA 92805 <br />Agency/ City Requesting Reimbursement <br />Payroll Total (Salaries, Overtime, Backfill, etc) <br />Travel Total (Tuition, Meals, Lodging, etc) <br />Equipment & Supplies Total <br />~ Total Amount Requested I _ <br />Under Penalty of perjury, I certify that: <br />I am the duly authorized officer of the claimant herein. This claim is in all respects true, correct, and all <br />expenditures were made in accordance with applicable laws, rules, regulations, and grant conditions and <br />assurances. All attached documents for items and/or services have been received in full. <br />Authorzed Agent i ~ <br />Printed Name <br />Title <br />Mailing Address <br />City, State, Zip Code <br />Signature (Please sign in blue ink) <br />Phone Number <br />E-Mail Address <br />Fax Number <br />Date <br />For Anaheim/Santa'Ana UASI Grant Coordinatior;'Use-Only <br />Approved for Processing Date <br />Account and Activity Number <br />Grant Year/Grant Project and Solution Area <br />Special Ins tructions/Comments <br />38 <br />