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EXAMPLE OF COST REPORT <br />STATE OF NORTH CAROLINA <br />DEPARTMENT OF CRIME CONTROL AND PUBLIC SAFETY <br />Homeland Security <br />4713 Mall Service Center <br />Raleigh, NC 27603 <br />COST REPORT <br />HOMELAND SECURITY <br />Vendor: <br />NCEM- OPERATIONS EMERGENCY SV <br />CFDA: 97.074 <br />Contact: <br />Steve Sloan <br />Address: <br />4713 Mail Service Center <br />Total <br />Raleigh, NC 27699 -4713 <br />Vendor Nbr /Fed ID Nbr: <br />56600000408 <br />0.00 <br />Account Nbr: <br />4701 - 53692010307 - 1520 - 030- H1-511 <br />Fund Code: <br />1520 <br />OSA Contract Number: <br />Prior Expenditures: <br />RCC: <br />030 <br />0.00 <br />Grant Identifier: <br />H1 <br />Grant Period: <br />7/1/2008 - 12/30/2010 <br />Project Code: <br />511 <br />MOA Nbr: <br />2007- GET -70048 -5006 <br />0.00 <br />Remarks: <br />/ <br />0.00 <br />Request # <br />Budget Worksheet <br />TRAINING <br />Total <br />Budget Amounts: <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />Prior Expenditures: <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0,00 <br />Current Balance: <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />Expended this <br />period: <br />Balance Remaining: <br />Funding Worksheet <br />Amount <br />Pmts to Date <br />Balance <br />% Funding <br />Reimbursement <br />New Balance <br />Federal <br />) <br />_ "1 <br />0.00 <br />100% <br />State <br />0.00 <br />0.00 <br />0% <br />Match <br />0.00 <br />0.00 <br />0.00 <br />0% <br />Subtotal <br />100% <br />Fed Admin <br />0.00 <br />0.00 <br />0.0 <br />0% <br />Total <br />Certification <br />I certify the above are correct, based on subgrentess official accounting system and records, consistently applied and maintained, and that expenditures <br />shown have been made for the purpose of and In accordance with, applicable grant terms and conditions, and that appropriate documentation to support <br />these costs and expenditures Is available or attached. <br />A <br />NCEM - OPERATIONS EMERGENCY SVC Authorized Signature Date <br />Homeland Security Approval Signature Date <br />Controller's Office Approval Date <br />Printed 10/22/201108:30:54 AM <br />Page 12 of 13 <br />VendorlD: 1231 <br />