2023 EMPG Expense Claim Form

	A	B	C	D	E	F
1	WYOMING OFFICE OF HOMELAND SECURITY
2	2023 EMPG Expense Claim Form
3
4	Jurisdiction:
5		Grant #:
6	Prepared by:	Award Period:
7	Phone: ( )	Requesting Period:
8	Email:
9
10	Payee/Vendor	Description of	AEL	Solution	Purchase/Service
11	Payee/Vendor	Expense	NUMBER*	Area (POETE)	Date(s)	TOTAL
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29	TOTAL AMOUNTS EXPENDED					$ -
30	FEDERAL SHARE (EMPG Reimbursement)		(If uneven, Round down extra penny)			$ -
31	Matching funds must come from non-federal sources and cannot be used toward meeting match/cost share requirements of another federal grant.
32	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
33
34	*Applies to equipment Solution Area only		Printed Title
35
36				Date
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100