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<br />Page 22 of 22 <br /> <br />ATTACHMENT 2 <br /> <br />MONTHLY FINANCIAL REPORT FORMAT <br /> <br />HMEP PLANNING GRANT MONTHLY FINANCIAL REPORT <br /> <br />LEPC: <br /> <br />Jurisdiction acting as fiscal agent: <br /> <br />For the Month of: <br /> <br />1. Project Cost (from Grant Agreement) <br />2, State Share (from Grant Agreement) <br />3, Local Match Share (from Grant Agreement) <br />4, Expenses previously submitted for State reimbursement <br /> <br />$ <br />$ <br />$ <br />$ <br /> <br />5, State reimbursement requested - this report <br /> <br />$ <br /> <br />Paid To <br /> <br />Date <br /> <br />Amount <br /> <br />Purpose <br /> <br />(An original and four copies of valid invoices or receipts and proof of payment for expenses (in the <br />form of canceled checks, bills marked "paid in full", or other proof) must be attached to this report <br />in order to receive state reimbursement for allowable expenses,) <br /> <br />6, Local match expenditures incurred <br />(Local match may be a cash match or a soft match, which could be one or more of the following: <br /> <br />A Salaries, fringe benefits, per diem, lodging, or travel expenses incurred by any person other <br />than a government employee while attending training classes or involved in program activities, <br /> <br />8, Public or private contributions of goods, such as paper, or services, such as printing, at fair <br />market value, <br /> <br />C, Voluntary contributions of labor by either public or private employees, valued at their normal <br />rate of pay. <br />D. Equipment used for exercises, whether public or private, valued at its normal rental rate. <br />E, Facilities necessary to conduct activities for the grant program, valued at market lease rates, <br />F, Students volunteering time, valued at prevailing minimum age,) <br /> <br />7. <br /> <br />State Share balance (Line 2 :... [4+5]) <br /> <br />$ <br /> <br />8, <br /> <br />Local Match Share balance (Line 3-6) <br /> <br />$ <br /> <br />Signature of Local Financial Officer <br /> <br />Title of Local Financial Officer <br />