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Rowest for Reitellnerseuseatt Pve4bisaster Miegatima Pimp** Project Number Date Project Title: Subgrantee: Project Applicant Agent: Manager: Address: , Arizona City, State, Zip Phone Number: Fax Number: E-Mail: Cost Status: I Grant Amount: Amount Disbursed Amount Requested TO your agency: BY your agency: I am requesting that the funds listed above be approved, in accordance with the following conditions: 1. Funds shall be credited to a special and separate account. 2. Funds shall be used solely for the work approved in the project application. 3. Funds advanced that are in excess of the approved actual expenditures, as accepted by final audit by the State, shall be refunded to the State. 4. Accounting records will be kept which adequately identify the source and application of PDM funds and be supported by such source documentation as canceled checks, paid bills, payrolls, time and attendance records, contract and subgrant awards, etc. Support documentation of all soft match dollars, such as force account labor and use of existing inventory, shall also be included. I certify that to the best of my knowledge and belief, the data presented above and on the attached worksheet are correct, that all outlays were made in accordance with the grant conditions and that payment is due and has not been previously requested. I further certify that I am the Authorized Applicant's Agent, designated by the above referenced applicant, to enter into this agreement for, and on behalf of, said applicant. Authorized Applicant's Agent Date ArLonci Division of Emergency Management 5636 E McDowell Road. Phoenix, Ari:otio 85008-3495 (602) 464-6349 1-800-411-2336 www.dem.azden2a2ov Miirch 2() () EXPENDITURE WORKSHEET Copies of check(s) payable to vendor(s) (or a bill of sale) must be submitted with this form. The attached documentation must equal the total amount requested. Project Title: Project No: VENDOR DESCRIPTION EXPENDITURES AMOUNT TO DATE REQUESTED 75% TOTAL .4rizona Division of Emergency Management 5636 E McDowell Road, Phoenix, Arizona 85008-3495 (602) 464-63-19 1-800-411-2336 1www.dem.azdema.zov March 7::