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SUS-GRANTEE REQUEST FOR PAYMENT <br /> 1. Subgrantee's Name (Payee) 2. Address (Number and Street) <br /> Hawaii County Fire Dept. 25 Aupuni Street #103 <br /> 3. City or Town 4. State 5. Zip Code <br /> Hilo HI 96720 <br /> 6. Agreement No. 7. Request No. S. Type of Request: <br /> O1 [ )Partial [ X ]Final <br /> 9. Project for which funds are being requested: <br /> Volunteer Fire Assistance <br /> 10. Agreement Period 11. Report Period: <br /> From: July 1, 2001 To: June 30, 2002 From: July 1, 2001 To: June 30, 2002 <br /> 12. Status of Funds: <br /> a. Grant Amount 50,000.00 <br /> b. Total Costs Incurred to Date 126,371.00 <br /> c. State Share of Total Costs 76,371.00 <br /> d. Non-State Share of Total Costs <br /> e. Retainage of State Share 5% <br /> f. State Share less Retainage <br /> g. Grant Funds Already Received <br /> h. Grant Funds Requested Now 50,000.00 <br /> * ATTACH SCHEDULE OF TOTAL COSTS INCURRED ITEMIZED BY MAJOR COSTS CATEGORIES AS DESCRIBED IN <br /> APPROVED BUDGET <br /> 13. Certification <br /> I certify that to the best of my knowledge and belief and the above costs are in accordance with the terms of the project as <br /> approved and that the reimbursement represents the State share currently due and has not been previously claimed on this or any <br /> other related project and that an inspection has been performed. <br /> I also understand that receipt of this reimbursement does not imply that all costs are allowable. All program costs are subject to <br /> audit and acceptance by the Grantor agency involved. <br /> au~ ~ zooz <br /> A thoriz d Subgrantee Signature & Title Date <br /> s**************s*********************************DLNR USE ONLY**************************s*s****************** <br /> <br /> Division Review <br /> <br /> Approved by: Date: <br /> Michael G. Buck, Administrator <br /> <br /> Fiscal Review <br /> <br /> By: Date: <br /> <br />