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["STATE OF ALASKA"]
["Department of Military and Veterans Affairs"]
["DIVISION OF HOMELAND SECURITY AND EMERGENCY MANAGEMENT"]
["STATEMENT OF DOCUMENTATION TO SUPPORT AMOUNT CLAIMED FOR FINANCIAL DISASTER ASSISTANCE"]
[]
["Applicant (State Agency, County, City District, Native Organization):",{"$nulls":7},"Disaster Number:",null,null,"State Application Number:"]
[]
[{"$nulls":8},"Project Worksheet (PW) Number:",null,null,"Category of Work:"]
[]
["Brief Description of Damaged Facility or Protective Measures:"]
{"$rows_empty":8}
[{"$nulls":6},"Approved PW Amount as listed in the Cost Est. of the obligated PW",{"$nulls":3},"Reported Costs Incurred \non the Project by the Applicant"]
["Force Account (In-house) Labor",{"$nulls":5},0,{"$nulls":3},0]
["Temporary Hire Labor",{"$nulls":5},0,{"$nulls":3},0]
["Materials",{"$nulls":5},0,{"$nulls":3},0]
["Force Account Equipment",{"$nulls":5},0,{"$nulls":3},0]
["Rental Equipment",{"$nulls":5},0,{"$nulls":3},0]
["Contract",{"$nulls":5},0,{"$nulls":3},0]
["Miscellaneous",{"$nulls":5},0,{"$nulls":3},0]
["Mitigation",{"$nulls":5},0,{"$nulls":3},0]
["Direct Administrative",{"$nulls":5},0,{"$nulls":3},0]
["Supplies",{"$nulls":5},0,{"$nulls":3},0]
[{"$nulls":6},0,{"$nulls":3},0]
["Insurance/Revenues",{"$nulls":5},0,{"$nulls":3},0]
["Total:",{"$nulls":4},{"$f":"SUM(F20:H30)-F31","v":0},{"$f":"SUM(G20:J30)-G31","v":0},{"$nulls":3},{"$f":"SUM(K20:N30)-K31","v":0}]
["Administrative Allowance",{"$nulls":5},0,{"$nulls":3},0,0]
[]
["I CERTIFY:"]
["- That all expenditures listed below are correct and cover only services performed or material used exclusively in disaster relief operations as authorized in the approved Project Worksheet."]
["- That to the best of my knowledge and belief, all work and costs are eligible in accordance with the grant conditions, all work claimed has been completed, and all costs have been paid in full."]
["- That salaries, wages and overtime payments claimed are in accordance with the applicant's policy as established prior to the disaster."]
["- That all work authorized in the approved Project Worksheet was completed and all essential services resumed within the time limit set forth in the approved Project Worksheet."]
[]
["Signature of Applicant's Authorized Representative",{"$nulls":7},"Date:",null,"Title:"]
[]
["For internal use by the Division of Homeland Security & Emergency Management"]
["Public Assistance Reviewer - Signature",{"$nulls":7},"Date:",null,"Approved PW Amount:"]

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