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<br />ATTACHMENT D <br /> <br />FLORIDA DEPARTMENT OF COMMUNITY AFFAIRS <br />DIVISION OF EMERGENCY MANAGEMENT <br /> <br />Request for Advance or Reimbursement for Public Assistance Funds <br /> <br />SUBGRANTEE NAME: <br /> <br />DEC NO: <br /> <br />ADDRESS: <br />PAYMENT NO: <br /> <br />PAIDNO: <br />DCA AGREEMENT NO: <br /> <br /> DSR DCA USE ONLY <br /> ELIOffiLE PREVIOUS CURRENT <br /> AMOUNT PAYMENTS REQUEST APPROVED <br /> FOR PAYMENT COMMENTS <br />DSR# <br />CATEGORY_ <br />% COMPLETE <br />DSR# <br />CATEGORY_ <br />% COMPLETE <br />DSR# <br />CATEGORY_ <br />% COMPLETE <br />DSR# <br />CATEGORY_ <br />% COMPLETE <br />DSR# <br />CATEGORY_ <br />% COMPLETE <br /> <br />TOTAL CURRENT REQUEST $ <br /> <br />I certify that to the best of my knowledge and belief the above accounts are correct and that all disbursements were made in accordance with all <br />conditions of the DCA agreement and payment is due and has not been previously requested for these amounts. <br /> <br />SUBGRANTEE SIGNATURE <br /> <br />NAME AND TITLE <br /> <br />DATE: <br /> <br />TO BE COMPLETED BY DEPARTMENT OF COMMUNITY AFFAIRS (DCA) <br />APPROVED FOR PAYMENT $ <br /> <br />ADMINISTRATIVE COST <br /> <br />$ <br />$ <br /> <br />GOVERNOR'S AUTHORIZED REPRESENTATIVE <br /> <br />TOTAL PAYMENT <br /> <br />DATE <br /> <br />D-l <br />