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									Commonwealth of Massachusetts
State 911 Department
FY2009 SETB Training Grant Reimbursement Form

Grant Recipient:
Name of Person Completing this Report:___________________________________
Phone number: _____________________________
                                        Date:___________________
Authorized Signature:_______________________________
Print Authorized Signature:___________________________________
This signature affirms your entity has paid these costs submitted for reimbursement and that these costs are in agreement
with the grant conditions and reporting requirements.

This worksheet must be accompanied by all payroll documents and/or receipts related to the amounts for reimbursement.


SUMMARY                                                                        TO BE COMPLETED BY SETB
                                           GRANT
                                         AWARDED             AMOUNT                AMOUNT                 DATE OF            AMOUNT
CATEGORY                                  AMOUNT            REQUESTED            REIMBURSED           REIMBURSEMENT         REMAINING

A. Training                                  $0

B. Overtime-Training Participants            $0
BB. Part-Time/Per Diem Employees-
Training Participants                        $0

C. Overtime-Replacement                      $0
CC. Part-Time/Per Diem Employees-
Replacement                                  $0

D. Academy Attendance                        $0

E. Lodging                                   $0

Total                                       $0.00

								
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