Laserfiche WebLink
Attachment D <br />Subgrant Number: <br />Name of Agency /City: <br />Project Title: <br />Telephone Number: <br />PRINT THIS PAGE ON YOUR LETTERHEAD <br />Edward Byrne Memorial Justice Assistance Grant Program <br />SUMMARY STATEMENT OF QUARTERLY PROJECT COSTS <br />Date: <br />Claim Number: <br />Claim Period: <br />Name of Person Completing Form: <br />1. Total Federal Budget 2. Amount of this Invoice <br />3. Amount of Previous Invoices 4. Remaining Budget Balance <br />$0,00 <br />(Subtract lines 2 & 3 from line 1) <br />AGENCY <br />FOR OMB USE <br />Requested Amount <br />ONLY: <br />for Reimbursement <br />Approved Amount <br />(as indicated on Line <br />for <br />Category 2 above) <br />Reimbursement <br />Salaries & <br />Benefits <br />Contractual <br />Services <br />Expenses <br />Operating Capital <br />Outlay <br />Total Claim Amount $0.00 <br />The above amount indicated as our agency's "Total Claim Amount" is being requested for reimbursement which is in accordance with our <br />contract agreement. Also, supporting documentation has been provided with this package which substantiates the above "Total Claim <br />Amount" requested by our agency. <br />I hereby certify that all of the costs have been paid and none of the items have been previously reimbursed. All of the expenditures <br />comply with the authorized budget and fall within the contractual scope of services and all of the goods and services have been <br />received, for which reimbursement is requested. <br />Respectfully submitted, <br />Authorized Signature (Chief of Police /Other City Official) <br />GIL Coding <br />Invoice Number <br />Vendor #: <br />Index Code: _ <br />Amount to Pay: <br />Subobject: <br />Resolution: <br />Payment Approved, Miami -Dade County OMB <br />FOR OMB USE ONLY <br />Invoice Description: <br />Voucher* VQBU <br />Package Reviewed by Liaison: _ <br />Date Submitted by Liaison in IWA: <br />SUPPORTING DOCUMENTATION FOR THIS PAYMENT MAINTAINED BY OMB - GRANTS COORDINATION <br />