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["Financial Commission for Appalachia HIDTA",null,null,null,null,null,"LC-07 (01-22) Pg. 1 of 2                                                    "]
["Request for Reimbursement"]
["1.  Agency Name:",null,null,"      6.  Initiative Name:"]
["2.  Agency Contact Person:",null,null,"      7.  Budget Year:"]
["3.  Agency Contact Phone:",null,null,"      8.  Period:"]
["4.  Agency Address:"]
[null,null,null,"      9.  Payment Information:",null,"All payments will be made via direct deposit to the bank account and routing numbers on file with the HIDTA Finance Office.  Please contact the HIDTA Finance Office at Finance@ahidta.org if any changes need to be made to your banking information."]
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["5a.  HIDTA Subaward"]
["5b.  Request #:"]
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["9.COMPUTATION OF AMOUNT OF REIMBURSEMENT REQUESTED:"]
["Account","Description",null,null,null,null,null,null,"Total Amount"]
["a. Personnel","Regular salary, including vacation and holiday, paid to agency employees (per your approved budget)"]
[null,"Account #",null,"Amount"]
[]
["b. Fringe","FICA, Retirement, Health, Life, Other Fringe Benefits paid in accordance with agency policies (per your approved budget)"]
[null,"Account #",null,"Amount"]
[]
["c. Overtime","Overtime per your approved budget.  (Note: check current year AHIDTA budget for overtime limits per employee.)",null,null,null,null,null,null,{"$f":"'Page 2'!$E$21","v":0}]
[null,"Account #",null,"Amount (Detail on Page 2 must be completed)"]
[null,null,null,"Total amount for OT will autofill from page 2"]
[]
["d. Travel","Investigative, administrative and training travel - lodging, per diem, air fare, vehicle rental, etc. (per your approved budget)"]
[null,"Account #",null,"Amount"]
[]
["e. Facilities","Lease of office space, warehouse, etc. Utilities, janitorial, improvements, maintenance, etc. (per your approved budget)"]
[null,"Account #",null,"Amount"]
[]
["f. Services","Lease/rental of equipment, phones, pagers, radios, copiers, vehicles, computers, data lines, audio/visual contractual services, workforce under contract for specific project, consultants (computer, investigative, litigation), Photo processing, repairs/maintenance (all except facilities) – service agreements, flight time, etc. (per your approved budget)"]
[null,"Account #",null,"Amount"]
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["g. Equipment","Purchase of Equipment $5,000 or more [Communications; Office (furniture, computer work stations, computers & accessories, copiers, fax machines, & others); Surveillance (electronics, specialized audio/phone, equip., lens, scopes, night vision); cameras, lenses, and related equipment; vehicles; video equipment, VCR, others] (per your approved budget)"]
[null,"Account #",null,"Amount"]
[]
["h. Supplies","Purchase of Supplies less than $5,000 Investigative/operational supplies, office supplies, software (per your approved budget)"]
[null,"Account #",null,"Amount"]
[]
["I. Other Costs","Purchase of Information/Evidence (per your approved budget)"]
[null,"Account #",null,"Amount"]
[]
[null,null,"Total Request Amount",null,null,null,null,null,{"$f":"I14+I17+I20+I24+I27+I30+I35+I38+I41","v":0}]
["Agency Authorized Certifying Official and Task Force Commander Certifications:"]
["1.  I certify that to the best of my knowledge and belief the data above are correct and that all outlays were made in accordance with the grant conditions and that payment has not been previously requested. "]
[" 2.  I certify that if funds for overtime reimbursement are being requested, that the total this agency has collected from Appalachia HIDTA for overtime for this officer/s does not exceed the Appalachia HIDTA limit of $19,000 per officer per calendar year and that the amount does not exceed the lower of : (1) applicable state, local, and tribal regulations of officer's parent agency: or (2) 25% of the Federal GS-12, Step 1 level pay scale for \"Rest of US\" in the law enforcement general schedule in effect at the beginning of the calendar year.  In addition, this overtime rate is the maximum that an officer can receive during the calendar year, fiscal year or other 12-month period from all Federal funding sources combined."]
["3. I also certify to the best of my knowledge that the overtime information on page 2 of this form is correct."]
["State Coordinator Certifications:"]
["1. Regarding overtime reimbursements-I certify that the officer/s listed are part of the AHIDTA task force and the overtime limit has not been exceeded.   2.  Regarding all other costs listed-I certify that I have reviewed the documentation and all costs appear reasonable and allowable to best of my knowledge. "]
["Signature of Agency Authorized Certifying Official",null,null,null,"Date"]
["State Coordinator Signature                                              Date",null,null,"Task Force Commander Signature",null,null,null,"Date"]
[null,null,null,null,null,null,"This form continued on page 2."]

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[null,null,null,null,"LC-07 (01-22) Pg. 2 of 2                      "]
["Item #9 c.-Overtime: "]
[null,null,null,"Calculation of Cumulative Overtime Reimbursement to-date"]
["A","B","C","D","E","F"]
["Officer Name","Is this employee eligible for overtime from parent agency?      Yes or No*","Number of overtime hours this officer worked this period in support of an AHIDTA Enforcement or Intelligence Initiative","HIDTA overtime reimbursement requested to-date (not including this request)","Overtime this agency paid this officer for hours listed in Column C                ","Total Overtime reimbursement requested to-date**                           (D + E = F)                 "]
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["TOTAL (Also enter on page 1 item 9c)",null,null,null,{"$f":"SUM(E6:E20)","v":0}]
[]
["*  If answer is \"No\", AHIDTA cannot reimburse this overtime."]
[]
["See page one of this form for certification language pertaining to this overtime reimbursement request."]
[]
["** Be advised that the total this agency has collected from Appalachia HIDTA for overtime for this officer/s cannot not exceed the Appalachia HIDTA limit of $19,000 per officer per calendar year and the amount cannot exceed the lower of : (1) applicable state, local, and tribal regulations of officer's parent agency: or (2) 25% of the Federal GS-12, Step 1 level pay scale for \"Rest of US\" in the law enforcement general schedule in effect at the beginning of the calendar year.  In addition, this overtime rate is the maximum that an officer can receive during the calendar year, fiscal year or other 12-month period from all Federal funding sources combined."]
["Responsibilities for Overtime Compliance (Per 2020 HIDTA Program Guidance Section 7.12.3)\nThe participating agency or initiative supervisor of the personnel receiving HIDTA-funded overtime shall ensure overtime is tracked, the maximum allowable amounts are not exceeded, the overtime is for HIDTA initiative-related activities, and the individual does not receive overtime compensation from another funding source for the same hours worked. \n"]
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["Records Availability and Records Retention:\nPer 2 CFR 200.336, AHIDTA requires that all original payroll documentation for this and any AHIDTA overtime reimbursement be made available for review purposes upon request for a three year period as described in 2 CFR 200.333.\n"]