Litter Control Grant Final Report Forms is sponsored by West Virginia Department of Environmental Protection. Covered Electronic Devices Grant Program All registration fees collected shall be deposited in the Covered Electronic Devices Takeback Fund which is to be administered by the Department of Environment Category: Environment.

## REAP LITTER GRANT FINAL PERFORMANCE AND ## ACCO UNTING REPORT FORM GRANT PERIOD: Ju ly 1, 2 02 __ THROUGH June 30, 20 2__ Report Prepared By: Email: Provide an evaluation of accomplishments in implementing the original proposal’s work tasks. You must provide applicable data below regarding your program during the grant period. No. of Community Cleanup Events: Did you utilize day report labor?

No. Litter/cigarette Receptacles Placed: Miles of roadway cleaned: > *If exact is unknown, you may multiply the number of bags by 20lbs. ## Please Note: Failure to comply with all grant reporting and deadlines will penalize future grant applications. Signature of Authorized Person Date EXPENDITURES REPORT LC-G-5 Applicant’s Name Did you include proof of deposit?

Y or N ACTUAL GRANT EXPENDITURES Required Documentation Included > Mark Y, N, or NA for each expenditure TO PURPOSE AMOUNT Invoice Proof of Payment ATTACH A COPY OF BANK STATEMENT SHOWING THE DEPOSIT OF THE GRANT FUNDS INTO YOUR ACCOUNT . You MUST attach copies of checks and invoices (include timesheets if you have personnel costs) to support the expenditures listed above.

Reimbursements to general accounts must be itemized along with backup documentation for each item. Unsupported expenditures will be disallowed by the Department of Environmental Protection.

MATCHING FUND REPORT LC-G-5 ACTUAL CASH EXPENDITURES FOR MATCH Required Documentation Included > Mark Y, No, or NA for each expenditure TO PURPOSE AMOUNT Invoice Proof of Payment ATTACH COPIES OF CHECKS, INVOICES, TIME SHEETS, TITLES, OR OTHER EVIDENCE TO SUPPORT THESE EXPENDITURES AND ESTIMATES. MAKE ADDITIONAL COPIES OF THIS FORM AS NECESSARY TO CONTINUE LISTING EXPENDITURES.

NAME OF VOLUNTEER SERVICE PROVIDED DATE HOURS WAGE RATE HRS x RATE PERSONNEL TIME SHEET RG-3C Grant Number Employee Position Title Rate of Pay $ per hr Pay Period Date Start Time End Time Total Time Details of Work Completed State of West Virginia Sworn Statement of Compliance W. Va.

Code §12-4-14 requires grantees of state funding to affirm compliance with the State of West Virginia’s requirements for eligibility to receive grant funding, including compliance and reporting requirements. This affirmation requirement may be incorporated within the formal grant agreement or may satisfied by utilizing this separate sworn statement of compliance document. Grantees should complete both Part A and Part B.

This Sworn Statement of Compliance is not valid unless completed in its entirety and notarized by a notary public in good standing with the Secretary of State. ## Part A.

Grantee / Grantor Information Grantee Name _________________________________________________________ D/B/A _________________________________________________________ wv OASIS Vendor ID # _____________________ Grantee Address _____________________________________________________ _____________________________________________________ _____________________________________________________ Telephone Number ___________________________________ State Agency Granting Funds _________________________________________________ State Grant # (if known) _______________________________________ CFDA / ALN # (if known/applicable) _______________________________________ Under penalty of law for false swearing (W.

Va. Code §61-5-3), ________________________________ certifies that by signing this sworn statement that _________________________________________ and all related parties have filed all reports for state grants received as required under W. Va.

Code §12-4-14. ______________________________________________ _____________________________ ## Part C.

Notary Public Affirmation Signed and sworn before me on _____________________________ by _______________________________________________________________________ _____________________________________ _______________________________ Notary Public Signature My commission expires Rev 11/2022 WV Department of Environmental Protection # Final Performance and Accounting Report Form Pre-Submission Checklist o Did you include proof of deposit?

(bank statement) o Did any of your purchases meet the threshold for bidding requirements? If so, submit the following:  Copy of Class II legal ad  Affidavit of Publication  Written approval from REAP to proceed with the purchase o Was your grant for labor wages? If so, you must submit detailed timesheets and copies of their paychecks and paystubs showing withholdings.

o Was your grant for Litter Control Officer wages? If so, please include a citation log to go with their time sheets and copies of their paychecks and paystubs. o Was your grant for roadside or open dump cleanups?

If so, please include a list of areas cleaned. o Was your grant for razing? If so, you must include before and after pictures.

o Was your grant for advertising? If so, you must include a copy of the advertisement (such as a tear sheet). o For ALL expenditures, you must submit a copy of the invoice and proof of payment, preferably check imaging.

Please refrain from issuing payments with a credit card. o For instances when you can only pay with a credit card, you will have to submit the following for proper reconciliation: invoice, receipt, credit card statement, and proof of payment to the credit card company. o Are you reimbursing a general account from the grant account?

If so, you must include the invoice, proof of the original method of payment, and proof of reimbursement to the original account. o Did you purchase any equipment over $1,000. 00?

If so, you must submit a notarized Security Agreement and a Certificate of Insurance listing WVDEP-REAP as the Certificate Holder. o Did your equipment purchase come with a title? If so, you MUST list WVDEP-REAP as first lien holder and submit the original title to us.

If you need blank forms, or if you have any questions regarding what must be submitted for the Final Performance and Accounting Report Form, please contract Travis Cooper at 304-926-0499 ext. 49754 or Travis. L.

Cooper@wv. gov .