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DocuSign Envelope ID: 70CDE96F-6D51-4BD6-93A5-3B3A2D3438CD <br /> STATE OF NORTH CAROLINA <br /> DEPARTMENT OF PUBLIC SAFETY <br /> "kwfto North Carolina Emergency Management <br /> Physical Address: 1636 Gold Star Drive, Raleigh, NC 27607-3371 <br /> Mailing Address:4236 Mail Service Center, Raleigh, NC 27699-4236 <br /> COST REPORT 1 - FISCAL YEAR 2015 <br /> EMERGENCY MANAGEMENT <br /> PERFORMANCE GRANT <br /> Grantee: Orange County Emergency Services <br /> Address: 510 Meadowlands Drive <br /> Hillsborough NC 28278- <br /> Federal ID No.: <br /> Account No.: <br /> Grant Period: 10/01/14 -09/30/16 <br /> Project: E]I IT6 <br /> Grant File No: EMPG-2015-37135 DUNS No.: 091575191 Branch: Central <br /> Funding 2015 EMPG Universal Amount Optional Amount SATCOM Balance to be Paid <br /> Worksheet Initial Amount (Base Amount) Deductions <br /> Federal/State $35,000.00 $35,000.00 TBD TBD $ 0 <br /> Local Match $35,000.00 $35,000.00 TBD TBD $ 0 <br /> Total $70,000.00 $70,000.00 TBD TBD $ 0 <br /> This is the first of two Cost Reports. This Initial Cost Report reflects the Universal (Base)Amount that your county is eligible to <br /> receive provided all Univeral activities are completed, and documentation is approved by the State before the designated <br /> deadline. This Cost Report requires appropriate signatures and return to the state for payment of eligible EMPG work activities <br /> completed to date. <br /> The second Cost Report will reflect completed and approved Optional work activity amounts by your Emergency Management <br /> program. SATCOM Deductions and a Balance to be Paid will also be reflected in Cost Report 2 to give you a total 2015 EMPG <br /> Final Amount award for your county. <br /> Please note that failure to complete any Universal activity will result in a 12.5% penalty per activity to be assessed <br /> against your 2016 EMPG funds. <br /> Certification: <br /> I certify the above are correct, based on grantee's 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 /> DOCUSigned by: <br /> O ,L� 11/20/2015 1 17:15:09 F <br /> 7D4E5181ACC1409... <br /> nge go n inance Officer Authorized Signature Date <br /> tS 11/20/2015 1 17:03:32 <br /> r I iNTrg_ency Services Authorized Signature Date <br /> 66��11 mer�7gVeOnfcyU/Management Director's Approval Signature Date <br /> �auxt S r,�t Vb�Ct 11/30/2015 1 08:42:03 <br /> aa=eto@XARmffilic Safety Controller's Office Approval Date <br /> Printed: 10/6/2015 2:21:47 PM 2015 Cost Report 1 <br />