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B. FISCAL REPORT <br /> <br /> ~[NEL <br /> <br />Personnel Number: Agency Funds State Funds Total Cost <br />Full -Time <br />Part -Time <br />Sub-Total <br /> <br />AND EXPENSES <br /> <br />Itemized Expenses Agency Funds State Funds Total Cost <br />Sub-Total <br /> <br />~T <br /> <br />Equipment (Itemized) Agency Funds State Funds Total Cost _ <br />Sub-Total <br /> <br /> Agency Funds State Funds* Total Cost <br />Grzot Total Costs <br /> <br /> * Total of State Funds must equal Amount of Payment on Agreement (Form SG-006). <br />Keep a copy of this report for your records. <br /> <br />"This is to certify that the State Funds requested were used only for the purposes set forth in Laws of <br />Minnesota 1997, Chapter 216, Sec. 5, Subd. 8 and the information contained in this form is correct to the <br />best of my knowledge." <br /> <br />Signature: <br /> <br />AGENCY ADMINISTRATOR: <br /> <br />TELEPHONE NUMBER <br /> <br /> <br />