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<br />Jurisdiction name: <br /> <br />Project Title: <br />Type of Reimbursement <br />Date Submitted <br />Reimbursement Period Start date: <br />Reimbursement Period End date: <br />Number of Months <br />Grant Year <br /> <br />Point of Contact: <br />Name <br />Title <br />Organization <br />Address <br /> <br />Email <br />Telephone <br />Fax <br /> <br />Certification Authority: <br />Name <br />Title <br />Payee Identification Number <br />Organization <br />Address <br /> <br />Email <br />Telephone <br />Fax <br /> <br />Certification AuthoritySignature <br /> <br />8AA I Division of Emergency Managment <br />Cost Reimbursement Request <br /> <br /> <br /> <br /> <br />By signing this document you are acknowledging that you are aware that you may be audited by TX DPS <br />and/or the Office of Grants and Training (G&T) to verify that this request is valid. Failure to provide correct <br />information could result in the disallowance and subsequent repayment of the entire amount requested. <br /> <br />Instructions <br /> <br />Step 1 - Complete the Point of Contact and Certification Authority Information. Enter requested reimbursement information by site <br />in the Cost Reimbursement Request spreadsheet. . <br /> <br />Step 2 - Submit the reimbursement package of forms and supporting documentation (for example, copies of canceled checks, <br />budget expenditure report, bank statement, and paid invoices) to the person in your jurisdiction who is the certification authority. <br />See definition of a Certification Signature Below. <br /> <br />Step 3 - Print and sign, then fax or mail a copy of the reimbursement package to the Governors Division of Emergency <br />Management/SM. The Fax number is 512-424-7825. The mailing address is: Governors Division of Emergency Management <br />attention:SM, PO Box 4087, Austin,TX 7Sn3-()ZTO <br /> <br />Step 4 - When the signed copy of the reimbursement package has been received by GDEM/SM the electronic transfer of funds to <br />the jurisdiction will be processed. <br /> <br />Definitions <br />Certification Signature: Signature of an individual who has the authority to sign legal documents for the jurisdiction. <br />Substantiating Documentation: could consist of invoices and procurement documentation. <br />Records Retention Schedule: Documentation substantiating this request must be kept until the end of the grant period plus three <br />years. <br /> <br />4/28/2006 <br />