EMPG Reimbursement Request Form

EMPG Reimbursement Request Form

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Confirmation Questions
This section serves as a reminder for additional reports that may be necessary for you to complete.
To begin, is this a final request for reimbursement (or a reimbursement request for all grant funds)?*
Additional Closeout Reports*
If this is a request for a final reimbursement (or for the entire grant amount), you are also required to submit the following forms or reports. These forms can be found on the EMPG Resource Center.
If you have not submitted these forms yet, please do so prior to submitting a Reimbursement Request.
By checking the box for each form below, you are confirming that each report has been completed.
- Equipment Inventory Form (for equipment projects only)
- Final Performance and Expenditure Report
- Audit Certification Form
Is this reimbursement request in an amount of $30,000 or more?*
If this request is for $30,000 or more you are also required to complete a FFATA Form on the EMPG Resource Center.*
The Federal Funding Accountability and Transparency Act (FFATA) Report is a form required by the Federal Government for grant funds expended at $30,000 or higher. This report must be completed for every request of funds over $30,000 for each project within a Federal grant.
If you have not completed the the FFATA Form yet, please do so here.
Contact and Project Information
Sub-Recipient Name (City/Town/Entity Name)*
Project Name*
Primary Point of Contact (POC)*
First Last
Primary POC Phone*
Primary POC Email*