MANAGEMENT AND ADMIN. (Up to 5%) $0.00 $0.00 $0.00 TOTAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 . AMOUNT OF REIMBURSEMENT FOR THIS CLAIM: By signing this report, I certify to the best of my know ledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 2022-2023 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE DATE QUARTERLY STATUS REPORT Please report EM activities, meetings, training, exercises, or other necessary information to support quarterly progression. THE SECTION BELOW IS TO BE COMPLETED BY DIVISION AWARD AMOUNT DIVISION DATE RECEIVED STAMP PRIOR CLAIMS THIS CLAIM AMOUNT BALANCE OF AWARD FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 1B - QUARTERLY TASKS RECIPIENT: QUARTER: July 1 - Sept. 30 Emergency Management Personnel EM Funded Staff Name & Position Title DELIVERABLES/TASK REQUIREMENTS ENTER DATE COMPLETED COMMENTS Use for explanation that supports Training & Exercise progression. QTR 1 QTR 2 QTR 3 QTR 4 T1: Provide Division Exhibit 3, certification of a full-time Emergency Management Director (Q1, any updates Q2-Q4) T1: Provide Division Form 4 - Staffing Detail and position descriptions for funded emergency management staff. (Q1, any updates Q2-Q4) T2: Provide Division Form 3 - Local Budget Match Requirement. (Q2, any updates Q3-Q4) T2: Submit a copy of the current and accurate County Emergency Management Local Budget (General Revenue) including the budget approval date (Q2, any updates Q3-Q4) T2: Submit a copy of the local EM general revenue expenditure (general ledger) report (Q2, any updates Q3-Q4) T3: Response Capabilities- Completean inventory of portable generators owned by the local governments which are capable of operating during a major disaster on the WEBEOC Equipment Inventory board no later than March 31, 2023. (Q3, any updates Q4) By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 2022-2023 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: 53 FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 2A - DETAIL OF CLAIMS RECIPIENT: INCURRED DATE RANGE: Example: July 1 through November 5, 2022 Please use separate Division Form 2A-Detail of Claims per allocation category. Please add additional pages or lines as needed for each allocation category. Please provide FEMA AEL numbers for EQUIPMENT expenditures only. Please provide a budget revision along with this form, if expenses being claimed are not allocated on the most recently approved budget. Please include the Costs Incurred Date Range in the applicable cell above. This is usually the quarterly period; however, a recipient may incorporate a larger date range to include a forgotten claim for reimbursement for a payment made the previous quarter (within the period of agreement). This allowance does not circumvent the four (4) required quarterly reporting forms submissions. TOTAL $ 300.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 2022-2023 EM PA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS 2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT PROGRAM DIVISION FORM 2B- DETAIL OF CLAIMS SALARIES AND FRINGE BENEFITS Pay Period: From: To: Sub-Recipient Name: Incurred Date Range: Claim #: DOES THIS CLAIM FOR REIMBURSMENT INCLUDE EXPENSES FOR ANY INCENTIVES OR SPECIAL PAY? Note: If this claim includes incentives or special pay, please provide FDEM with the written established policy for support. EM Funded staff Name Total Salary Amount FICA/Medicare Retirement Employee Life Insurance Health/Dental Insurance Workers Comp Incentive Pay (If, Applicable) Total Fringe Benefits $ 15,000.00 SubTotals $ 15,000.00 $ - Total Cost Charged to the Grant $ 15,000.00 "By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accurate, and the expenditures, disbursements and cash receipts are for the pruposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fradulent information, or the ommission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and TItle 31, Sections 3729-3730 and 3801- 3812)." SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA LOCAL BUDGET MATCH REQUIREMENT DIVISION FORM 3 - LOCAL BUDGET MATCH 2022-2023 LOCAL 2021-2022 LOCAL 2020-2021 LOCAL 2019-2020 LOCAL AVERAGE (PREVIOUS 3 LOWEST AVERAGE VS PREVIOUS % 2021-2022 VS $ CHANGE 2021-2022 VS $ CHANGE 2021-2022 VS RECIPIENT (10/1/21- 9/30/22) (10/1/20- 9/30/21) (10/1/19- 9/30/20) (10/1/18- 9/30/19) YEARS) YEAR AVERAGE AVERAGE 2020-2021 Florida County (name) $100,000 $95,000 $90,000 $85,000 $90,000 2020-2021 10% $10,000 $5,000 This form is to be completed and sent when the Local County Budget is approved or by the end of the first quarter. Required with this form the recipient shall provide a copy of the current Emergency Management Local Budget (General Revenue) with the approved buget date. If the Recipient's county's current budget is lower than the last year or the average of the last three previous years, the county is required to request a waiver from the Division no later than forty-five (45) days after the county budget is approved. RULE 27P-19, FLORIDA ADMINISTRATIVE CODE
Appears in 2 contracts
MANAGEMENT AND ADMIN. (Up to 5%) $0.00 $0.00 $0.00 TOTAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 . AMOUNT OF REIMBURSEMENT FOR THIS CLAIM: By signing this report, I certify to the best of my know ledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222021-2023 2022 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE DATE QUARTERLY STATUS REPORT Please report EM activities, meetings, training, exercises, or other necessary information to support quarterly progression. THE SECTION BELOW IS TO BE COMPLETED BY DIVISION AWARD AMOUNT DIVISION DATE RECEIVED STAMP PRIOR CLAIMS THIS CLAIM AMOUNT BALANCE OF AWARD FY 2021 – 2022 – 2023 EMPA AGREEMENT ATTACHMENT FJ-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222021-2023 2022 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 1B - QUARTERLY TASKS RECIPIENT: QUARTER: July 1 - Sept. 30 Emergency Management Personnel NIMS IS 100 NIMS IS 200 NIMS IS 700 NIMS IS 800 FEMA Prof essional Development Series OR National Emergency Management Basic Academy EM Funded Staff Employee Name & Position Title QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 DELIVERABLES/TASK REQUIREMENTS ENTER DATE COMPLETED COMMENTS Use for explanation that supports Training & Exercise progression. QTR 1 QTR 2 QTR 3 QTR 4 T1: Provide Division Exhibit 3, certification of a full-time Emergency Management Director or part-time Coordinator. (Q1, any updates Q2-Q4) T1: Provide Division Form 4 - Staffing Detail and position descriptions for funded emergency management staff. (Q1, any updates Q2-Q4) T1: Provide a quarterly report as outlined in Quarterly Reports (Attachment A(3)). (Q1-Q4) T1: Provide full-time Emergency Management Director's or part- time Coordinator's certified timesheets or paystubs. (Q1-Q4) T2: Provide Division Form 3 - Local Budget Match Requirement. (Q2, any updates Q3-Q4) T2: Submit a copy of the current and accurate County Emergency Management Local Budget (General Revenue) including the budget approval date (Q2, any updates Q3-Q4) T2: Submit a copy of the local EM general revenue expenditure (general ledger) report (Q2, any updates Q3-Q4) T3: Statewide Mutual Aid Agreement (Attachment F(1)) - Submit the current excel Statewide Mutual Aid Agreement (SMAA) list by September 30, 2021. (Q1, any updates Q2-Q4) T3: Response Capabilities- Completean inventory Capabilities (Attachment G) - Maintain current county emergency management and other contacts through the Division's SharePoint Portal including County Director and Alternate contacts. (Q3, any updates Q4) T3: Response Capabilities (Attachment G) - Maintain GIS site data in the Division's SharePoint Portal. (Q3, any updates Q4) T3: Response Capabilities (Attachment G) - Maintain site data in WEBEOC to include County Staging Areas (CSAs) and County Points of portable generators owned by Distribution (PODs). (Q3, any updates Q4) T3: Response Capabilities (Attachment H) - Complete the local governments which are capable of operating during a major disaster SESP Shelter Inventory and Retrofit Items 1-8 on the WEBEOC Equipment SESP Shelter Inventory board no later than March 31, 20232022. (Q3, ) T4: Recovery Capabilities (Attachment I) - Identify any updates potential Disaster Recovery Center (DRC) locations and provide basic information in WEBEOC. (Q4) By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222021-2023 2022 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: 53 FY 2021 – 2022 – 2023 EMPA AGREEMENT ATTACHMENT FJ-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222021-2023 2022 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 2A - DETAIL OF CLAIMS RECIPIENT: INCURRED DATE RANGE: Example: July 1 through November 5, 2022 2021 Please use separate Division Form 2A-Detail of Claims per allocation category. Please add additional pages or lines as needed for each allocation category. categ Please provide FEMA AEL numbers for EQUIPMENT expenditures only. Please provide a budget revision along with this form, if expenses being claimed are not allocated on the most recently approved budget. Please include the Costs Incurred Date Range in the applicable cell above. This is usually the quarterly period; however, a recipient may incorporate a larger date range to include a forgotten claim for reimbursement for a payment made the previous quarter (within the period of agreement). This allowance does not circumvent the four (4) required quarterly reporting forms submissions. TOTAL $ 300.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222021-2023 2022 EM PA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2021 – 2022 – 2023 EMPA AGREEMENT ATTACHMENT FJ-REPORTING FORMS 2022FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2021-2023 2022 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT PROGRAM - EMPA DIVISION FORM 2B- 2B - DETAIL OF CLAIMS SALARIES AND FRINGE BENEFITS Pay PeriodCOSTS SALARY DEFINITION: FromThe cash compensation for services rendered by a regular employee in an established position for a specific period of time. RECIPIENT: To: Sub-Recipient Name: Incurred Date Range: Claim Florida County CLAIM #: DOES THIS CLAIM FOR REIMBURSMENT INCLUDE EXPENSES FOR ANY INCENTIVES OR SPECIAL PAY? Note: If this claim includes incentives or special pay, please provide FDEM with the written Division w ith the w xxxxxx established policy for support. support EM Funded staff Name Total Salary Amount FICA/Medicare Retirement Employee Life Insurance Health/Dental Insurance Workers Comp Incentive Pay (If, Applicable) Total Fringe Benefits EMPLOYEE NAME EM POSITION TITLE % TIME CHARGED TO EMPA SALARY FRINGE BENEFITS 1 Ex: Xxxx Xxx EM Planner 50% $ 15,000.00 SubTotals 5,000.00 $ 15,000.00 1,200.00 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTALS $ - Total Cost Charged to the Grant 5,000.00 $ 15,000.00 "1,200.00 TOTAL $ 6,200.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accuratecomplete, accurate and the expenditures, disbursements and cash receipts are for the pruposes purposes and objectives set forth in the terms and conditions of the Federal award2021-2022 EM PA agreement. I am aware that any false, fictitious, or fradulent information, or the ommission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and TItle 31, Sections 3729-3730 and 3801- 3812)." SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2021 – 2022 – 2023 EMPA AGREEMENT ATTACHMENT FJ-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222021-2023 2022 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA LOCAL BUDGET MATCH REQUIREMENT DIVISION FORM 3 - LOCAL BUDGET MATCH 2022-2023 LOCAL 2021-2022 LOCAL 2020-2021 LOCAL 2019-2020 LOCAL 2018-2019 LOCAL AVERAGE (PREVIOUS 3 LOWEST AVERAGE VS PREVIOUS % 20212020-2022 2021 VS $ CHANGE 20212020-2022 2021 VS $ CHANGE 20212020-2022 2021 VS RECIPIENT (10/1/21- 9/30/22) (10/1/20- 9/30/21) (10/1/19- 9/30/20) (10/1/18- 9/30/19) YEARS) YEAR AVERAGE AVERAGE 20202019-2021 2020 Florida County (name) $100,000 $95,000 $90,000 $85,000 $90,000 2020-2021 AVERAGE 10% $10,000 $5,000 This form is to be completed and sent when the Local County Budget is approved or by the end of the first quarter. Required with this form the recipient shall provide a copy of the current Emergency Management Local Budget (General Revenue) with the approved buget date. If the Recipient's county's current budget is lower than the last year or the average of the last three previous years, the county is required to request a waiver from the Division no later than forty-five (45) days after the county budget is approved. RULE 27P-19, FLORIDA ADMINISTRATIVE CODE
Appears in 2 contracts
Samples: Grant Agreement, Funded Grant Agreement
MANAGEMENT AND ADMIN. (Up to 5%) $0.00 $0.00 $0.00 TOTAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 . AMOUNT OF REIMBURSEMENT FOR THIS CLAIM: By signing this report, I certify to the best of my know ledge knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE DATE QUARTERLY STATUS REPORT Please report EM activities, meetings, training, exercises, or other necessary information to support quarterly progression. THE SECTION BELOW IS TO BE COMPLETED BY DIVISION AWARD AMOUNT DIVISION DATE RECEIVED STAMP PRIOR CLAIMS THIS CLAIM AMOUNT BALANCE OF AWARD FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 1B - QUARTERLY TASKS RECIPIENT: QUARTER: July 1 - Sept. 30 Emergency Management Personnel NIMS IS 100 NIMS IS 200 NIMS IS 700 NIMS IS 800 FEMA Professional Development Series OR National Emergency Management Basic Academy EM Funded Staff Employee Name & Position Title QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 DELIVERABLES/TASK REQUIREMENTS ENTER DATE COMPLETED COMMENTS Use for explanation that supports Training & Exercise progression. QTR QRT 1 QTR QRT 2 QTR QRT 3 QTR QRT 4 T1: Provide Division Exhibit 34, certification of a full-time Emergency Management Director or part-time Coordinator. (Q1, any updates Q2-Q4) T1: Provide Division Form 4 - Staffing Detail and position descriptions for funded emergency management staff. (Q1, any updates Q2-Q4) T1: Provide a quarterly report as outlined in Quarterly Reports (Attachment (A3). (Q1-Q4) T1: Provide full-time Emergency Management Director's or part- time Coordinator's certified timesheets or paystubs. (Q1-Q4) T2: Provide the Division Form 3 - Local Budget Match Requirement. (Q2, any updates Q3-Q4) T2: Submit a copy of the current and accurate County Emergency Management Local Budget (General Revenue) including the budget approval date (Q2, any updates Q3-Q4) T2: Submit a copy of the local EM general revenue expenditure (general ledger) report (Q2, any updates Q3-Q4) T3: Response Capabilities- Completean inventory Capabilities (Attachment F) - Maintain current county emergency management and other contacts through the Division's SharePoint Portal including County Director and Alternate contacts. (Q3, any updates Q4) T3: Response Capabilities (Attachment F) - Upload current GIS site data to the Division's SharePoint Portal. (Q3, any updates Q4) T3: Response Capabilities (Attachment F - Upload current site data into WebEOC to include County Staging Areas (CSAs) and County Points of portable generators owned by Distribution (PODs). (Q3, any updates Q4) T3: Attachment G - Complete Hurricane Shelter Retrofit items A-G in the local governments which are capable of operating during a major disaster on the WEBEOC Equipment Inventory board worksheet and upload into WebEOC no later than March 31, 20232021. T4: Recovery Capabilities (Attachment H) - Identify any potential Disaster Recovery Center (DRC) locations and provide basic information in WebEOC. (Q3, any updates Q4) By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: 53 FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 2A - DETAIL OF CLAIMS RECIPIENT: INCURRED DATE RANGE: Example: July 1 through November 5, 2022 2020 Please use separate Division Form 2A-Detail of Claims per allocation category. Please add additional pages or lines as needed for each allocation category. Please provide FEMA AEL numbers for EQUIPMENT expenditures only. Please provide a budget revision along with this form, if expenses being claimed are not allocated on the most recently approved budget. Please include the Costs Incurred Date Range in the applicable cell above. This is usually the quarterly period; however, a recipient may incorporate a larger date range to include a forgotten claim for reimbursement for a payment made the previous quarter (within the period of agreement). This allowance does not circumvent the four (4) required quarterly reporting forms submissions. ALLOCATION CATEGORIES CATEGORY: PLEASE SELECT FROM THE LIST BELOW ORGANIZATION # VENDOR DESCRIPTION OF SERVICE OR EXPENSE DATE OF PAYMENT FOR SERVICE OR EXPENSE (Include full date) PAYMENT REFERENCE (CHECK#, PO#, JT#, etc.) PURCHASE AMOUNT Equipment FEMA AEL# (N/A if equipment was not purchased) 1 Ex: Electric Company Monthly Utilities for July 2020 8/5/20 CK# 1001 $ 300.00 N/A 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 TOTAL $ 300.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts arefor the purposes and objectives set forth in the conditions of the 2020-2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2020-2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 2B - DETAIL OF CLAIMS SALARIES AND BENEFITS COSTS SALARY DEFINITION: The cash compensation for services rendered by a regular employee in an established position for a specific period of time. RECIPIENT: Florida County CLAIM #: DOES THIS CLAIM FOR REIMBURSMENT INCLUDE ANY INCENTIVES OR SPECIAL PAY? Note: If this claim includes incentives or special pay, please provide the Division with the written established policy for support. EM EMPLOYEE NAME EM POSITION TITLE % TIME CHARGED TO EMPA SALARY FRINGE BENEFITS 1 Ex: Xxxx Xxx EM Planner 50% $ 5,000.00 $ 1,200.00 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTALS $ 5,000.00 $ 1,200.00 TOTAL $ 6,200.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 EM PA 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS 2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT PROGRAM DIVISION FORM 2B- DETAIL OF CLAIMS SALARIES AND FRINGE BENEFITS Pay Period: From: To: Sub-Recipient Name: Incurred Date Range: Claim #: DOES THIS CLAIM FOR REIMBURSMENT INCLUDE EXPENSES FOR ANY INCENTIVES OR SPECIAL PAY? Note: If this claim includes incentives or special pay, please provide FDEM with the written established policy for support. EM Funded staff Name Total Salary Amount FICA/Medicare Retirement Employee Life Insurance Health/Dental Insurance Workers Comp Incentive Pay (If, Applicable) Total Fringe Benefits $ 15,000.00 SubTotals $ 15,000.00 $ - Total Cost Charged to the Grant $ 15,000.00 "By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accurate, and the expenditures, disbursements and cash receipts are for the pruposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fradulent information, or the ommission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and TItle 31, Sections 3729-3730 and 3801- 3812)." SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA LOCAL BUDGET MATCH REQUIREMENT DIVISION FORM 3 - LOCAL BUDGET MATCH 2022-2023 LOCAL 2021-2022 LOCAL RECIPIENT 2020-2021 LOCAL 2019-2020 LOCAL 2018-2019 LOCAL 2017-2018 LOCAL AVERAGE (PREVIOUS 3 YEARS) LOWEST AVERAGE VS PREVIOUS YEAR % 20212020-2022 2021 VS AVERAGE $ CHANGE 20212020-2022 2021 VS AVERAGE $ CHANGE 20212020-2022 2021 VS RECIPIENT (10/1/21- 9/30/22) 2019-2020 (10/1/20- 9/30/21) (10/1/19- 9/30/20) (10/1/18- 9/30/19) YEARS(10/1/17- 9/30/18) YEAR AVERAGE AVERAGE 2020-2021 Florida County (name) $100,000 $95,000 $90,000 $85,000 $90,000 2020-2021 AVERAGE 10% $10,000 $5,000 This form is to be completed and sent when the Local County Budget is approved or by the end of the first quarter. Required with this form the recipient shall provide a copy of the current Emergency Management Local Budget (General Revenue) with the approved buget date. If the Recipient's county's current budget is lower than the last year or the average of the last three previous years, the county is required to request a waiver from the Division no later than forty-five (45) days after the county budget is approved. RULE 27P-19, FLORIDA ADMINISTRATIVE CODE
Appears in 1 contract
Samples: Agreement
MANAGEMENT AND ADMIN. (Up to 5%) $0.00 $0.00 $0.00 TOTAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 . AMOUNT OF REIMBURSEMENT FOR THIS CLAIM: By signing this report, I certify to the best of my know ledge knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE DATE QUARTERLY STATUS REPORT Please report EM activities, meetings, training, exercises, or other necessary information to support quarterly progression. THE SECTION BELOW IS TO BE COMPLETED BY DIVISION AWARD AMOUNT DIVISION DATE RECEIVED STAMP PRIOR CLAIMS THIS CLAIM AMOUNT BALANCE OF AWARD FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 1B - QUARTERLY TASKS RECIPIENT: QUARTER: July 1 - Sept. 30 Emergency Management Personnel NIMS IS 100 NIMS IS 200 NIMS IS 700 NIMS IS 800 FEMA Professional Development Series OR National Emergency Management Basic Academy EM Funded Staff Employee Name & Position Title QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 DELIVERABLES/TASK REQUIREMENTS ENTER DATE COMPLETED COMMENTS Use for explanation that supports Training & Exercise progression. QTR QRT 1 QTR QRT 2 QTR QRT 3 QTR QRT 4 T1: Provide Division Exhibit 34, certification of a full-time Emergency Management Director or part-time Coordinator. (Q1, any updates Q2-Q4) T1: Provide Division Form 4 - Staffing Detail and position descriptions for funded emergency management staff. (Q1, any updates Q2-Q4) T1: Provide a quarterly report as outlined in Quarterly Reports (Attachment (A3). (Q1-Q4) T2: Provide the Division Form 3 - Local Budget Match Requirement. (Q2, any updates Q3-Q4) T2: Submit a copy of the current and accurate County Emergency Management Local Budget (General Revenue) including the budget approval date (Q2, any updates Q3-Q4) T2: Submit a copy of the local EM general revenue expenditure (general ledger) report (Q2, any updates Q3-Q4) T3: Response Capabilities- Completean inventory Capabilities (Attachment F) - Maintain current county emergency management and other contacts through the Division's SharePoint Portal including County Director and Alternate contacts. (Q3, any updates Q4) T3: Response Capabilities (Attachment F) - Upload current GIS site data to the Division's SharePoint Portal. (Q3, any updates Q4) T3: Response Capabilities (Attachment F - Upload current site data into WebEOC to include County Staging Areas (CSAs) and County Points of portable generators owned by Distribution (PODs). (Q3, any updates Q4) T3: Attachment G - Complete Hurricane Shelter Retrofit items A-G in the local governments which are capable of operating during a major disaster on the WEBEOC Equipment Inventory board worksheet and upload into WebEOC no later than March 31, 20232021. T4: Recovery Capabilities (Attachment H) - Identify any potential Disaster Recovery Center (DRC) locations and provide basic information in WebEOC. (Q3, any updates Q4) By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: 53 FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 2A - DETAIL OF CLAIMS RECIPIENT: INCURRED DATE RANGE: Example: July 1 through November 5, 2022 2020 Please use separate Division Form 2A-Detail of Claims per allocation category. Please add additional pages or lines as needed for each allocation category. Please provide FEMA AEL numbers for EQUIPMENT expenditures only. Please provide a budget revision along with this form, if expenses being claimed are not allocated on the most recently approved budget. Please include the Costs Incurred Date Range in the applicable cell above. This is usually the quarterly period; however, a recipient may incorporate a larger date range to include a forgotten claim for reimbursement for a payment made the previous quarter (within the period of agreement). This allowance does not circumvent the four (4) required quarterly reporting forms submissions. ALLOCATION CATEGORIES CATEGORY: PLEASE SELECT FROM THE LIST BELOW ORGANIZATION # VENDOR DESCRIPTION OF SERVICE OR EXPENSE DATE OF PAYMENT FOR SERVICE OR EXPENSE (Include full date) PAYMENT REFERENCE (CHECK#, PO#, JT#, etc.) PURCHASE AMOUNT Equipment FEMA AEL# (N/A if equipment was not purchased) 1 Ex: Electric Company Monthly Utilities for July 2020 8/5/20 CK# 1001 $ 300.00 N/A 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 TOTAL $ 300.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts arefor the purposes and objectives set forth in the conditions of the 2020-2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2020-2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 2B - DETAIL OF CLAIMS SALARIES AND BENEFITS COSTS SALARY DEFINITION: The cash compensation for services rendered by a regular employee in an established position for a specific period of time. RECIPIENT: Florida County CLAIM #: DOES THIS CLAIM FOR REIMBURSMENT INCLUDE ANY INCENTIVES OR SPECIAL PAY? Note: If this claim includes incentives or special pay, please provide the Division with the written established policy for support. EM EMPLOYEE NAME EM POSITION TITLE % TIME CHARGED TO EMPA SALARY FRINGE BENEFITS 1 Ex: Xxxx Xxx EM Planner 50% $ 5,000.00 $ 1,200.00 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTALS $ 5,000.00 $ 1,200.00 TOTAL $ 6,200.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 EM PA 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS 2022-2023 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT PROGRAM DIVISION FORM 2B- DETAIL OF CLAIMS SALARIES AND FRINGE BENEFITS Pay Period: From: To: Sub-Recipient Name: Incurred Date Range: Claim #: DOES THIS CLAIM FOR REIMBURSMENT INCLUDE EXPENSES FOR ANY INCENTIVES OR SPECIAL PAY? Note: If this claim includes incentives or special pay, please provide FDEM with the written established policy for support. EM Funded staff Name Total Salary Amount FICA/Medicare Retirement Employee Life Insurance Health/Dental Insurance Workers Comp Incentive Pay (If, Applicable) Total Fringe Benefits $ 15,000.00 SubTotals $ 15,000.00 $ - Total Cost Charged to the Grant $ 15,000.00 "By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accurate, and the expenditures, disbursements and cash receipts are for the pruposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fradulent information, or the ommission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and TItle 31, Sections 3729-3730 and 3801- 3812)." SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2022 – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA LOCAL BUDGET MATCH REQUIREMENT DIVISION FORM 3 - LOCAL BUDGET MATCH 2022-2023 LOCAL 2021-2022 LOCAL RECIPIENT 2020-2021 LOCAL 2019-2020 LOCAL 2018-2019 LOCAL 2017-2018 LOCAL AVERAGE (PREVIOUS 3 YEARS) LOWEST AVERAGE VS PREVIOUS YEAR % 20212020-2022 2021 VS AVERAGE $ CHANGE 20212020-2022 2021 VS AVERAGE $ CHANGE 20212020-2022 2021 VS RECIPIENT (10/1/21- 9/30/22) 2019-2020 (10/1/20- 9/30/21) (10/1/19- 9/30/20) (10/1/18- 9/30/19) YEARS(10/1/17- 9/30/18) YEAR AVERAGE AVERAGE 2020-2021 Florida County (name) $100,000 $95,000 $90,000 $85,000 $90,000 2020-2021 AVERAGE 10% $10,000 $5,000 This form is to be completed and sent when the Local County Budget is approved or by the end of the first quarter. Required with this form the recipient shall provide a copy of the current Emergency Management Local Budget (General Revenue) with the approved buget date. If the Recipient's county's current budget is lower than the last year or the average of the last three previous years, the county is required to request a waiver from the Division no later than forty-five (45) days after the county budget is approved. RULE 27P-19, FLORIDA ADMINISTRATIVE CODE
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Samples: Agreement
MANAGEMENT AND ADMIN. (Up to 5%) $0.00 $0.00 $0.00 TOTAL $0.00 105,806.00 $6,500.00 $0.00 $0.00 $0.00 $0.00 6,500.00 $0.00 $0.00 99,306.00 . AMOUNT OF REIMBURSEMENT FOR THIS CLAIM: By signing this report, I certify to the best of my know ledge knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE DATE QUARTERLY STATUS REPORT Please report EM activities, meetings, training, exercises, or other necessary information to support quarterly progression. THE SECTION BELOW IS TO BE COMPLETED BY DIVISION AWARD AMOUNT DIVISION DATE RECEIVED STAMP PRIOR CLAIMS THIS CLAIM AMOUNT BALANCE OF AWARD FY 2022 ATTACHMENT I – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 1B - QUARTERLY TASKS RECIPIENT: QUARTER: July 1 - Sept. 30 Emergency Management Personnel NIMS IS 100 NIMS IS 200 NIMS IS 700 NIMS IS 800 FEMA Professional Development Series OR National Emergency Management Basic Academy EM Funded Staff Employee Name & Position Title QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 QRT 1 QRT 2 QRT 3 QRT 4 DELIVERABLES/TASK REQUIREMENTS ENTER DATE COMPLETED COMMENTS Use for explanation that supports Training & Exercise progression. QTR QRT 1 QTR QRT 2 QTR QRT 3 QTR QRT 4 T1: Provide Division Exhibit 32, certification of a full-time Emergency Management Director or part-time Coordinator. (Q1, any updates Q2-Q4) T1: Provide Division Form 4 - Staffing Detail and position descriptions for funded emergency management staff. (Q1, any updates Q2-Q4) T1: Provide a quarterly report as outlined in Quarterly Reports (Attachment (A3). (Q1-Q4) T2: Provide the Division Form 3 - Local Budget Match Requirement. (Q2, any updates Q3-Q4) T2: Submit a copy of the current and accurate County Emergency Management Local Budget (General Revenue) including the budget approval date (Q2, any updates Q3-Q4) T2: Submit a copy of the local EM general revenue expenditure (general ledger) report (Q2, any updates Q3-Q4) T3: Response Capabilities- Completean inventory Capabilities (Attachment F) - Maintain current county emergency management and other contacts through the Division's SharePoint Portal including County Director and Alternate contacts. (Q3, any updates Q4) T3: Response Capabilities (Attachment F) - Upload current GIS site data to the Division's SharePoint Portal. (Q3, any updates Q4) T3: Response Capabilities (Attachment F - Upload current site data to into WebEOC to include County Staging Areas (CSAs) and County Points of portable generators owned by Distribution (PODs). (Q3, any updates Q4) T3: Attachment G - Complete the local governments which are capable of operating during a major disaster on Hurricane Shelter Retrofit items A- G in the WEBEOC Equipment Inventory board worksheet and upload into WebEOC no later than March 31, 20232021. T4: Recovery Capabilities (Attachment H) - Identify any potential Disaster Recovery Center (DRC) locations and provide basic information in WebEOC. (Q3, any updates Q4) By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: 53 FY 2022 ATTACHMENT I – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA DIVISION FORM 2A - DETAIL OF CLAIMS RECIPIENT: INCURRED DATE RANGE: Example: July 1 through November 5, 2022 2020 Please use separate Division Form 2A-Detail of Claims per allocation category. Please add additional pages or lines as needed for each allocation category. Please provide FEMA AEL numbers for EQUIPMENT expenditures only. Please provide a budget revision along with this form, if expenses being claimed are not allocated on the most recently approved budget. Please include the Costs Incurred Date Range in the applicable cell above. This is usually the quarterly period; however, a recipient may incorporate a larger date range to include a forgotten claim for reimbursement for a payment made the previous quarter (within the period of agreement). This allowance does not circumvent the four (4) required quarterly reporting forms submissions. ALLOCATION CATEGORIES PLEASE SELECT FROM THE LIST BELOW TOTAL $ 300.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the conditions of the 20222020-2023 EM PA 2021 EMPA agreement. SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2022 ATTACHMENT I – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS 2022FLORIDA DIVISION OF EMERGENCY MANAGEMENT 2020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT PROGRAM - EMPA DIVISION FORM 2B- 2B - DETAIL OF CLAIMS SALARIES AND FRINGE BENEFITS Pay PeriodCOSTS SALARY DEFINITION: FromThe cash compensation for services rendered by a regular employ established position for a specific period of time. ee in an RECIPIENT: To: Sub-Recipient Name: Incurred Date Range: Claim Florida County CLAIM #: DOES THIS CLAIM FOR REIMBURSMENT INCLUDE EXPENSES FOR ANY INCENTIVES OR SPECIAL PAY? Note: If this claim includes incentives or special pay, please provide FDEM the Division with the written established policy for support. EM Funded staff Name Total Salary Amount FICA/Medicare Retirement Employee Life Insurance Health/Dental Insurance Workers Comp Incentive Pay (If, Applicable) Total Fringe Benefits EMPLOYEE NAME EM POSITION TITLE % TIME CHARGED TO EMPA SALARY FRINGE BENEFITS 1 Ex: Xxxx Xxx EM Planner 50% $ 15,000.00 SubTotals 5,000.00 $ 15,000.00 1,200.00 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTALS $ - Total Cost Charged to the Grant 5,000.00 $ 15,000.00 "1,200.00 TOTAL $ 6,200.00 By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accuratecomplete, accurate and the expenditures, disbursements and cash receipts are for the pruposes purposes and objectives set forth in the terms and conditions of the Federal award2020-2021 EMPA agreement. I am aware that any false, fictitious, or fradulent information, or the ommission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and TItle 31, Sections 3729-3730 and 3801- 3812)." SIGNATURE: AUTHORIZED REPRESENTATIVE PRINTED NAME: TITLE: DATE: FY 2022 ATTACHMENT I – 2023 EMPA AGREEMENT ATTACHMENT F-REPORTING FORMS FLORIDA DIVISION OF EMERGENCY MANAGEMENT 20222020-2023 2021 EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE GRANT - EMPA LOCAL BUDGET MATCH REQUIREMENT DIVISION FORM 3 - LOCAL BUDGET MATCH 2022-2023 LOCAL 2021-2022 LOCAL RECIPIENT 2020-2021 LOCAL 2019-2020 LOCAL 2018-2019 LOCAL 2017-2018 LOCAL AVERAGE (PREVIOUS 3 YEARS) LOWEST AVERAGE VS PREVIOUS YEAR % 20212020-2022 2021 VS AVERAGE $ CHANGE 20212020-2022 2021 VS AVERAGE $ CHANGE 20212020-2022 2021 VS RECIPIENT (10/1/21- 9/30/22) 2019-2020 (10/1/20- 9/30/21) (10/1/19- 9/30/20) (10/1/18- 9/30/19) YEARS(10/1/17- 9/30/18) YEAR AVERAGE AVERAGE 2020-2021 Florida County (name) $100,000 $95,000 $90,000 $85,000 $90,000 2020-2021 AVERAGE 10% $10,000 $5,000 This form is to be completed and sent when the Local County Budget is approved or by the end of the first quarter. Required with this form the recipient shall provide a copy of the current Emergency Management Local Budget (General Revenue) with the approved buget date. If the Recipient's county's current budget is lower than the last year or the average of the last three previous years, the county is required to request a waiver from the Division no later than forty-five (45) days after the county budget is approved. RULE 27P-19, FLORIDA ADMINISTRATIVE CODE
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Samples: Agreement
