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WYOMING OFFICE OF HOMELAND SECURITY
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2021 EMPG Reimbursement Request
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Jurisdiction:
Total Award Amount:
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Payee (If different from above):
Grant Project ID #:
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Prepared By:
Award Period:
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Phone:Email:
Request Period:
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Please complete all sections of Reimbursement Request and Expense Claim Forms. Incomplete requests will be returned for completion.
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1. Total Amount Reimbursed to Date
(Do not include match)
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2. Total Amount Expended (from Expense Claim Form) $ -
(Including Match and Federal Share)
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3. Total Federal Share (From Expense Claim Form) $ -
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4. Have you completed and turned in all Quarterly Reports to date?Yes or No
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5. Is this your final reimbursement request?Yes or No
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PLEASE ATTACH EXPENSE CLAIM FORM LISTING ALL EXPENDITURES.
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I certify to the best of my ability that all purchases are for the purpose of the grant and are allowable as defined in the Notice of Funding Opportunity and Grant Award Agreement with the Wyoming Office of Homeland Security. All expenses listed on the Expense Claim form have been paid/and or ordered and the appropriate invoice is included with this request. In addition, all supporting documentation is on file in the office of record and available for review or audit. Copies of documentation will be retained for a minimum of three (3) years after the close of the grant or resolution of any audit issues.
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Authorized Signature: ____________________________________
Date: _____________________________
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WOHS Use Only:
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Reimbursement request is:
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Approved:Modified to:Denied:
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Reason for Modification or Denial:_____________________________________________________________________________________
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Date Received:
Drawdown Number:
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Remaining Balance
$
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Approved by:
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Program Manager
Date
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