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? Rrint Form; .
<br />FINANLir.L_ REPORT FORM ?.,dil original and support documenfiation:
<br /> Cuyahoga County Public Safety Grants Administration
<br /> 1276 West 3rd Street, #325
<br />A. GRANT: ? (Ph) 216-443-5681 (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. E]] Check BoxlMarked "F" if Final Report for this Grant. Street Address:
<br />' City, State Zip:
<br />Payment Request:
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<br />GRANT ADMINISTRATIQN
<br />TOTAL COST
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<br />FEDERAUSTATE FUND
<br />CASH MATCH
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<br />TOTAL COST
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<br />?dTHERPROJECTaNCOME ?:
<br />DJA/ES USE ONLY:
<br />
<br />CURRENT RECEIPTS
<br />YTD RECEIPTS
<br />YTD EXPENDITURES
<br />BALANCE !
<br />
<br />1 CERTIFY THAT ALL TRANSACTIONS REPORTED ABOVE HAVE This Report Prepared By:
<br />BEEN MADE IN COMPLIANCE WITH ALL APPLICABLE STATUTES Name:
<br />AND REGULATfONS, AND IN ACCORDANCE WITH THE APPROVED Title:
<br />GRANT AWARD. Address:
<br />Designated Official Signature:
<br />Phone No.:
<br /> Fax No
<br />: Report Reviewed and Approved By:
<br />Typed Name and Title: .
<br /> e-mail:
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