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[]
[null,"DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT\nDIVISION OF STATE FINANCIAL ASSISTANCE \nSTATE GRANT MANAGEMENT \n2020 West El Camino, 4th Floor\nSacramento, CA  95833"]
[]
[]
[]
[]
[]
[]
[null,"PET ASSISTANCE AND SUPPORT (PAS) PROGRAM"]
[null,"REQUEST FOR FUNDS"]
[null,"Last Updated 3/28/2022"]
[null,"HCD Contract Number:",null,null,null,null,null,null," HCD SGM Rep Name:"]
[null,"Project Name:",null,null,null,null,null,null," Request for Funds #:",null,null,null,null,null,null,null,null,null,null,1,2,3,4,5,6,7,8,9,10]
[null,"Project Address:",null,null,null,null,null,null," Preparer  Name:"]
[null,"Contractor Name:",null,null,null,null,null,null," Preparer Title:"]
[null,"Contractor Address:",null,null,null,null,null,null," Preparer E-mail:"]
[null,"Contractor City/State/Zip:",null,null,null,null,null,null," Preparer Phone #:"]
[null,"Total PAS Award:"]
[null,"EXPENDITURE BREAKDOWN"]
[null,"Activity Name",null,"Award Amount",null,"Total Previously Drawn",null,"Draw Amount Requested This Period",null,"Total Drawn To Date ",null,"Percent of Award Drawn",null,"Award Remaining",null,"HCD Approved Draw Amount This Period"]
[null,"Food - Animals",null,null,null,null,null,null,null,{"$f":"SUM(F21+H21)","v":0},null,{"$f":"IF(D21,J21/D21,0)","v":0},null,{"$f":"SUM(D21-J21)","v":0}]
[null,"Kennels/Crates",null,null,null,null,null,null,null,0,null,0,null,{"$f":"SUM(D22-J22)","v":0}]
[null,"Veterinarian Services",null,null,null,null,null,null,null,0,null,0,null,0]
[null,"Staff (for assisting pets) ",null,null,null,null,null,null,null,0,null,0,null,0]
[null,"Liability Insurance (PAS)",null,null,null,null,null,null,null,0,null,0,null,0]
[null,"Independent Audit (PAS)",null,null,null,null,null,null,null,{"$f":"SUM(F26,H26)","v":0},null,0,null,0]
[null,"TOTAL:",null,{"$f":"SUM(D21:D26)","v":0},null,{"$f":"SUM(F21:F26)","v":0},null,{"$f":"SUM(H21:H26)","v":0},null,{"$f":"SUM(J21:J26)","v":0},null,{"$f":"IF(D27>0,J27/D27,0)","v":0},null,{"$f":"SUM(N21:O26)","v":0}]
[null,"CERTIFICATION"]
[null,"***By signing this request, I certify to the best of my knowledge and belief that the request is true, complete, and accurate, and the expenditures, disbursements and cash receipts will be  for the purposes and objectives set forth in the terms and conditions of the State award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)"]
[null,"Name of Authorized Person",null,null,null,null,null,null,null,null,"Title of Authorized Person "]
[]
[null,"Signature of Authorized Person ",null,null,null,null,null,null,null,null,"Date"]
[]
[null,"HCD USE ONLY"]
[null,"     SGM Representative Signature                                                                ",null,null,null,null,null,null,null,null,"     Date"]
[]
[null,"     SGM Manager Signature                                                                ",null,null,null,null,null,null,null,null,"     Date"]

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[]
[]
[null,null,"DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT\nDIVISION OF FINANCIAL ASSISTANCE \nSTATE GRANT MANAGEMENT \n2020 West El Camino, 4th Floor\nSacramento, CA  95833\nPhone: (916) 263-1501"]
[]
[]
[]
[]
[]
[]
[null,null,"PET ASSISTANCE AND SUPPORT (PAS) PROGRAM"]
[null,null,"REQUEST FOR FUNDS"]
[]
[null,null,"Contract Number:","Enter Contract Number here",null,null,null,null,null,"SGM Rep Name:"]
[null,null,"Project Name:","Enter Name of the Project here",null,null,null,null,null,"Funds Request #:"]
[null,null,"Applicant Name:","Enter Name of the Applicant here",null,null,null,null,null,"Preparer  Name:"]
[null,null,"Co-Applicant Name:","Enter Name of Co-Applicant here",null,null,null,null,null,"Preparer Title:"]
[null,null,"Project Address:","Enter physical Project's Address here",null,null,null,null,null,"E-mail:"]
[null,null,"Project City/State/Zip:","Enter Project's address City/State/Zip here",null,null,null,null,null,"Phone Number:"]
[]
[null,null,"EXPENDITURE BREAKDOWN"]
[]
[null,null,"Activity Name",null,"Approved Budget",null,"Total Previously Drawn",null," Amount Requested This Period",null,"Total Drawn To Date",null,"Percent of Approved Budget Drawn",null,"Budget Remaining",null,"HCD Approved Amount"]
[]
[null,null,"Pet Assistance And Support",null,0,null,0,null,0,null,{"$f":"SUM(G24+I24)","v":0},null,{"$f":"IF(E24,K24/E24,0)","v":0},null,{"$f":"SUM(E24-K24)","v":0},null,0]
[]
[null,null,"Food - Animals",null,0,null,0,null,0,null,{"$f":"SUM(G26+I26)","v":0},null,{"$f":"IF(E26,K26/E26,0)","v":0},null,{"$f":"SUM(E26-K26)","v":0},null,0]
[]
[null,null,"Veterinarian Services",null,0,null,0,null,0,null,{"$f":"SUM(G28+I28)","v":0},null,{"$f":"IF(E28,K28/E28,0)","v":0},null,{"$f":"SUM(E28-K28)","v":0},null,0]
[]
[null,null,"Staff (for assisting pets) ",null,0,null,0,null,0,null,{"$f":"SUM(G30+I30)","v":0},null,{"$f":"IF(E30,K30/E30,0)","v":0},null,{"$f":"SUM(E30-K30)","v":0},null,0]
[]
[null,null,"Liability Insurance (PAS)",null,0,null,0,null,0,null,{"$f":"SUM(G32+I32)","v":0},null,{"$f":"IF(E32,K32/E32,0)","v":0},null,{"$f":"SUM(E32-K32)","v":0},null,0]
[]
[null,null,"Independent Audit (PAS)",null,0,null,0,null,0,null,{"$f":"SUM(G34,I34)","v":0},null,{"$f":"IF(E34,K32M/K34,0)","v":0},null,{"$f":"SUM(E34-K34)","v":0},null,0]
[]
[null,null,"TOTAL:",null,{"$f":"SUM(E23:E34)","v":0},null,{"$f":"SUM(G23:G34)","v":0},null,{"$f":"SUM(I24,I26,I28,I30,I32,I34)","v":0},null,{"$f":"SUM(K24,K26,K28,K30,K32,K34)","v":0},null,{"$f":"IF(E36,K36/E36,0)","v":0},null,{"$f":"SUM(O24,O26,O28,O30,O32,O34)","v":0},null,{"$f":"SUM(Q24,Q26,Q28,Q30,Q32,Q34)","v":0}]
[]
[null,null,"CERTIFICATION"]
[null,null,"***By signing this request, I certify to the best of my knowledge and belief that the request is true, complete, and accurate, and the expenditures, disbursements and cash receipts will be  for the purposes and objectives set forth in the terms and conditions of the State award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)"]
[]
[null,null,"Name and Title of Authorized Person ",null,null,null,null,null,null,null,"Date"]
[null,null,"     "]
[null,null,"Signature of Authorized Person"]
[]
[]
[null,null,"HCD USE ONLY"]
[null,null,"SGM Representative Signature                                                                "]
[null,null,null,null,null,null,null,null,null,null,"Date"]
[null,null,"SGM Manager Signature                                                                "]
[null,null,null,null,null,null,null,null,null,null,"Date"]