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WYOMING OFFICE OF HOMELAND SECURITY
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2022 EMPG Expense Claim Form
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Jurisdiction:
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Grant #:
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Prepared by: Award Period:
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Phone: ( )Requesting Period:
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Email:
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Payee/VendorDescription ofAEL SolutionPurchase/Service
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ExpenseNUMBER*Area (POETE)Date(s)TOTAL
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TOTAL AMOUNTS EXPENDED $ -
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FEDERAL SHARE (EMPG Reimbursement) (If uneven, Round down extra penny) $ -
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Matching funds must come from non-federal sources and cannot be used toward meeting match/cost share requirements of another federal grant.
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I hereby certify that all expenses claimed hereon have been paid in full and supporting documentation is attached. Furthermore, it is certified that all sections of this form have been completed to the fullest and best of my ability. Signature of Authorized Official
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*Applies to equipment Solution Area onlyPrinted Title
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Date
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