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Emergency Management Assistance Compact (EMAC)
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Intrastate Reimbursement Summary Form R-2
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Event:
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Requesting State/Province:
Date Submitted:
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Resource Provider:
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Resource Provider / Vendor Number:
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State Mission Number:
EMAC Mission Number:
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Copies of all source documentation to support expenses in this claim are attached (please select):
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Personnel Costs
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Total Regular Hours $ - Total Regular Fringe $ -
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Total Overtime Hours $ - Total Overtime Fringe $ -
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Total Backfill Hours $ - Total Backfill Fringe $ -
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Total Holiday Pay Hours $ - Total Holiday Pay Fringe $ -
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Total Compensatory Hours $ - Total Compensatory Fringe $ -
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Total Personnel Costs $ -
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Travel Costs
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Meals: Per Diem $ - Meals: Receipt $ -
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Air Travel $ - Airfare Baggage and Fees $ -
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Lodging $ - Parking/Tolls $ -
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POV/GOV/Rental $ - POV/GOV/Mileage and Fuel $ -
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Total Travel Costs $ -
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Equipment Costs
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Equipment by Rate $ - Equipment Repair/Replacement $ -
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Total Equipment Costs $ -
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Commodity Costs
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Total Commodity $ -
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Total Commodity Costs $ -
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Other Costs
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Other by Rate $ - Other by Quantity $ -
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Total Other Costs $ -
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Total Reimbursement $ -
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Total Donated $ -
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Comments
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REIMBURSEMENT PACKAGE CERTIFICATION
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By signing below, you the authorized official of the Resource Provider, certifies that the totals for each category/claim represents the actual costs expended in performance of the requested services identified in the RSA/Mission Order and that all expenditures were made in accordance with the Resource Provider’s pre-existing policies. You also certify that all accompanying support to the claim is source documentation and shall be considered accurate and complete.
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Certified and Authorized By:
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Print NameTitleDate
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Signaturev 11/23/21
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