Fillable FORM A: EXPENDITURE REPORT/REQUEST FOR PAYMENT: (Hillsborough County)

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FORM A: EXPENDITURE REPORT/REQUEST FOR PAYMENT: (Hillsborough County)

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FORM A: EXPENDITURE REPORT/REQUEST FOR PAYMENT
HILLSBOROUGH COUNTY ECONOMIC DEVELOPMENT DEPARTMENT
REBUILD COMMUNITY-BASED BUSINESSES GRANT PROGRAM
AWARDEE:
AMOUNT REQUESTED:
TO BE COMPLETED BY COUNTY STAFF:
ACCT CODE:
APPROVED:
NOTE: EXHIBIT D MUST BE ATTACHED TO EACH EXPENDITURE REPORT/ REQUEST FOR PAYMENT
Dates of Reporting Period:
1. REPORTING SUMMARY
A. County Grant Funds claimed:
Total amount paid by Awardee for which reimbursement is sought $
(Proof of payment must be attached)
2. DOCUMENTS TO SUPPORT REPORTING SUMMARY
Attach Forms B & C to Form A, along with all required documentation of expenditures, and indicate whether such items
are attached:
1. Form B: List of Expenditures attached:
□
2. Proof of Payment and Invoices attached or all expenditures: □
3. Form C: Report Narrative attached: □
3. Photographic documentation of impact attached: □
3. REPORT CERTIFICATION:
I affirm, under penalty of perjury, that this report represents an accurate and complete description of the grant
activity within the report dates above, and that the conditions of the Grant Award, as set forth in the Hillsborough
County Rebuild Community-based Businesses Grant Award Agreement, have been complied with.
Signature of Authorized Representative Signature of person completing this form (if not Authorized Representative)
Date Date
Printed Name and Title Printed Name and Title
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FORM B: LIST OF EXPENDITURES
HILLSBOROUGH COUNTY REBUILD COMMUNITY-BASED BUSINESSES GRANT PROGRAM
List all expenditures for which reimbursement is sought and attach invoices and proof of payment for each item.
1. PURPOSE OF EXPENDITURE:
Documentation Submitted:
Invoice
Proof of
Completion
Proof of
Payment
Invoice #
Invoice Date
Invoice Amount
$
Grant Amount Claimed:
Payment # Payment Date Payment Amount
$
$
2. PURPOSE OF EXPENDITURE:
Documentation Submitted:
Invoice
Proof of
Completion
Proof of
Payment
Invoice #
Invoice Date
Invoice Amount
$
Grant Amount Claimed:
Payment # Payment Date Payment Amount
$
$
3. PURPOSE OF EXPENDITURE:
Documentation Submitted:
Invoice
Proof of
Completion
Proof of
Payment
Invoice #
Invoice Date
Invoice Amount
$
Grant Amount Claimed:
Payment # Payment Date Payment Amount
$
$
4. PURPOSE OF EXPENDITURE:
Documentation Submitted:
Invoice
Proof of
Completion
Proof of
Payment
Invoice #
Invoice Date
Invoice Amount
$
Grant Amount Claimed:
Payment # Payment Date Payment Amount
$
$
5. PURPOSE OF EXPENDITURE:
Documentation Submitted:
Invoice
Proof of
Completion
Proof of
Payment
Invoice #
Invoice Date
Invoice Amount
$
Grant Amount Claimed:
Payment # Payment Date Payment Amount
$
$
The purpose of each expenditure must be stated clearly and in enough detail for the County to determine that the expenditure is
appropriate. Attach copies of invoices and corresponding cancelled checks (or equivalent documentation as approved by the County)
for all grant funded expenditures listed above. Please organize and label these attachments appropriately.
Please attach additional pages as necessary.
Initial Here:
TOTAL AMOUNT CLAIMED FOR GRANT FUNDS: _
FORM C:
HILLSBOROUGH COUNTY
REBUILD COMMUNITY-BASED BUSINESSES GRANT PROGRAM
REPORT NARRATIVE
AWARDEE:
REPORT PERIOD: THROUGH
I. IMPACT: Please provide a brief narrative that describes how funds provided by the Rebuild Community-based Businesses Grant
Program positively impacted your business (i.e. repairs, improvements, restocking of inventory, reopening, retaining employees), and
whether funding provided by the County was able to be leveraged for additional support:
II. SUPPORTING ATTACHMENTS: Please provide photographic documentation of repairs and improvements made to facilities.
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FORM A: EXPENDITURE REPORTREQUEST FOR PAYMENT: (Hillsborough County)

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Completed 22 August 2020

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