Reimbursement Submission

LEO Grant Reimbursement 2025-26

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Basic Information

Date of Submission*

Name of Agency*

LEO Grant Approval Number*

Mailing Address*

Address City State Zip

Agency Contact Name*

First Middle Last Suffix

Agency Contact Phone*

Agency Contact Email Address*

Signatory Authorized Official*

(This is the name of the mayor, board of supervisors president, commissioner, head of agency, school board president, etc. that would be authorized to sign for the grant application and any subsequent oversight)

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Signatory Authorized Official Email Address*

Description of Submitted Documents and Information

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Documents Submitted

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Application Submission Compliance

I certify that I am an employee of the aforementioned agency or have been hired by the agency to apply on their behalf for the Grant. All parties have knowledge and approved all information and documentation. I certify the costs submitted and the submitted projects are in compliance with all state and/or federal laws and regulations. I will immediately update and return any funds subsequently found to be unnecessary or otherwise not used or returned. By signing I also agree to submit, without objection, to any audits of the grant funds.

Name of Applicant*

First Last

Title

Signature*

Date of Signature*

Reimbursement Submission

LEO Grant Reimbursement 2025-26

Basic Information

Description of Submitted Documents and Information

Documents Submitted

Application Submission Compliance

Mailing Address

Physical Address

Office Hours