HMA Cash Advance Supporting Documentation Submission

Contact Information
Sub-Recipient Name (Municipality/Entity Name)*
Primary Point of Contact (POC)*
First Last
Primary POC Email*
Enter Email Confirm Email
Primary POC Phone*
Project Information
Funding Source*
Project Name*
Total Amount Spent*
Please only include costs with supporting documentation submitted within this form.
Federal Share Spent*
This is automatically calculated based on the amount entered above. Federal Share is 75% of eligible project costs.
Documentation Upload
Cash Advance Supporting Documentation Letter*
Please upload a Cash Advance Supporting Documentation Letter on town letterhead. Please include a task based narrative and/or a cost breakdown table. Please only include costs with supporting documentation submitted within this form.
Max. file size: 1 GB.
Proof of Cost*
Please upload all documentation related to the cost of the project (i.e., vendor invoices)
Drop files here or

Max. file size: 1 GB.
Proof of Payment*
Please upload all documentation related to the payment of the above invoices (i.e., copies of cancelled checks, bank statements, credit card statements)
Drop files here or

Max. file size: 1 GB.
Additional Supporting Documentation
Please provide any additional documentation here.
Drop files here or

Max. file size: 1 GB.
Certification and Submission
The person completing this submission is the same as the Primary POC*
- Yes
- No
Name of Person Completing the Submission*
First Last
Email of Person Completing the Submission*
Enter Email Confirm Email
Phone Number of Person Completing the Submission*
By selecting the box below and entering my name, I agree and understand that providing any false information may result in the inability to distribute any further monies or benefits related to this project until a complete and accurate report has been sent to NH HSEM.*
- I understand and agree
By selecting the box below and entering my name, I certify that the contracted costs associated with this project have been acquired in full accordance with my entity's procurement policy and the federal procurement requirements found in 2 CFR §200. I also understand that in the absence of an agreed upon procurement policy for my entity, I certify that I have followed the federal procurement requirements found in 2 CFR §200.*
- I Understand and Agree
Name*
First Last
Comments
Provide any additional comments or notes that you would like to share with HSEM regarding this submission.
Comments
This field is for validation purposes and should be left unchanged.

HMA Cash Advance Supporting Documentation Submission

HMA Cash Advance Supporting Documentation Submission

Contact Information

Project Information

Documentation Upload

Certification and Submission

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