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FINANCI REPORT FORM ail original ancJ support documentation:
<br /> ,,uyahoga County Public Safefy Grants Administration
<br />f 310 Lakeside Ave Suite 795A
<br />A. GRANT: (Ph) 296-443-5681 (Fax) 443-5773
<br />B. AWARDEE: E. Subgrantee: Board of Cuyahoga County Commissioners
<br /> Street Address: 1219 Ontario Street
<br />C. Report Period Ending: City, State Zip: Cleveland, Ohio 44113
<br /> F. Implementing Agency:
<br />D. [] Check Box/Marked "F" if Final Report for this Grant. Street Address:
<br /> City, State Zip:
<br />Payment Request:
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<br />FEDERAL/STATE FUND
<br />CASH MATCH
<br />IN-KIND MATCH
<br />T07'AL COST
<br />l1 FtJ1? GAS ?,,,?
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<br />DJA/ES USE ONLY
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<br />CURRENT RECEIPTS
<br />YTD RECEIPTS
<br />YTD EXPENDITURES
<br />BALANCE
<br />
<br />I CERTIFY THAT ALL TRANSACTIONS REPORTED ABOVE HAVE This Report Prepared By:
<br />BEEN MADE IN COMPLIANCE WlTH ALL APPLICABLE STATUTES Name:
<br />AND REGULATIONS, AND IN ACCORDANCE WITH THE APPROVED Title:
<br />GRANT AWARD. Address:
<br />Designated Official Signature:
<br /> Phone No.: ?
<br />Typed Name and Title: Fax No.: Report Reviewed and Approved By:
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