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WYOMING OFFICE OF HOMELAND SECURITY
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2020 NSGP Grant 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:
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Phone:Email:Drawdown Request #:
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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. Cumulative Previous Request
(Total of all previous requests)
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2. Total Amount of this Request
(Amount requested on this drawdown)
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3. Is this your final reimbursement request?Yes or No
(Circle One)
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Reimbursement Checklist:Request Form
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Expense Claim Form
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Invoice
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Proof of Payment
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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
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Program Guidance. All expenses listed on the Expense Claim form have been paid for and/or ordered and the appropriate
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supporting documentation is included with this request. In addition, all supporting documentation is on file and will
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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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Signature: Date:
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WOHS Use Only:
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Reimbursement request is:
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Approved:
Denied:
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Modified: Reason:
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Drawdown Number:
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Date Received:
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Remaining Balance
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Approved by:
Program Manager
Date
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