CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES (Cal OES)
AUTHORIZED AGENT
NOTE: Unauthorized alterations will delay the approval of this request.
City of Riverside ALN: HSGP 97.067
065-62000
2024-XXXX
Supporting Information for Application, Modification, or Request for Federal Funds This claim is for costs incurred within the grant performance period.
Initial Application September 1, 2024 May 31, 2027
This request is for a/an: through
Beginning Performance Period Date Ending Performance Period Date $2,894,900
Request # Amount This Request
Under Penalty of Perjury, I certify that:
I am the duly authorized officer of the claimant herein. This claim is true, correct, and all expenditures were made in accordance with applicable laws, rules, regulations, and grant conditions and assurances.
Statement of Certification - Authorized Agent
By signing this report, I certify, to the best of my knowledge and belief, that the report is true, complete, and accurate, and that the expenditures, disbursements, and cash eceipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or th mission of any material fact, may subiect me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 100 and Title 31, Sections 3729-3730 and 3801-3812).
Mike Futrell 3900 Main Street
Printed Name of Authorized Agent Payment Address
City Manager Riverside, CA 92522-0002
Title of Authorized Agent City, ZIP
Approved as to Form:
Signature of Authorized Agent Date
Bv:
Jacob S. Guerard
Deputy City Attorney
FY 2023 HSGP FMFW (Macro) v.23 2 of 2 AA Approval