EMPG Quarterly Reporting Form

EMPG Quarterly Progress Reporting Form
Contact and Project Information
Performance Period*
Sub-Recipient Name (City/Town/Entity Name)*
Sub-Recipient Address*
Street Address City State ZIP Code
Sub-Recipient Phone*
Primary Point of Contact (POC)
First Last
Primary POC Phone
Federal Fiscal Year of Grant*
This can be found on your signed Grant Agreement or Award Letter sent to you by the EMPG Program Coordinator.
Project Name*
Please select the project type*
Risk Indicator*
The Risk Indicator can be found in your EMPG Award Letter.

Certification and Submission
By Selecting the Box Below and entering my name and today's date, I agree that I understand that these forms are required to be submitted on a quarterly basis. I understand that failure to report by the deadline or 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. In addition, failure to report on time may result in the loss of future funding/grant awards.*
- I understand and Agree
Name*
First Last
Submission Date*
MM slash DD slash YYYY
Email*
Enter Email Confirm Email
If you would like, please enter an additional e-mail address for a copy of the Quarterly Report to be sent to.
Enter Email Confirm Email
Email
This field is for validation purposes and should be left unchanged.

EMPG Quarterly Progress Reporting Form