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HomeMy WebLinkAboutExhibit 7ATTACHMENT C PAYMENT REQUEST FORM GRANTEE: GRAN'TEE'S GRANT MANAGER; DEP AGREEMENT NO.: PAYMENT REQUEST NO.: PERFORMANCE DATE OF REQUEST: PERIOD; AMOUNT REQUESTED:$ PERCENT MATCHING REQUIRED: GRANT EXPENDITURES SUMMARY SECTION [Effective Date of Grant through End -of -Grant Period] CATEGORY OF EXPENDITURE AMOUNT OF THIS CLAIM TOTAL CUMULATIVE FCMP CLAIMS MATCHING FUNDS CLAIMED TOTAL CUMULATIVE MATCHING FUNDS Salaries $ $ $ $ Fringe Benefits $ $ $ $ Travel $ $ $ $ Equipment Purchases 1.$ $ $ $ Supplies $ S $ $ Contractual Services $ S $ $ Construction $ $ $ $ Other Expenses $ $ $ $ Indirect $ $ $ , TOTAL AMOUNT $ $ $ $ GRANT BUDGET AMOUNT Less Total Cumulative Payments op. $ REMAINING BUDGET IN GRANT GRANTEE CERTIFICATION The undersigned certifies that the amount being requested for reimbursement above was for items that were charged to and utilized only for the above cited grant activities, Grantee's Grant Manager's Signature Grantee's Fiscal Agent Print Name Print Name Telephone Number Telephone Number "PLEASE DO NOT ALTER THIS FORM*" DEP Agreement No. CZ613, Attachment C, Page 1 ol'3 INSTRUCTIONS FOR COMPLETING ATTACHMENT C PAYMENT REQUEST FORM GRANTEE: Enter the name of the grantee's agency. DEP AGREEMENT NO.: This is the number on your grant agreement that starts with CZ6 DATE OF REQUEST. This is the date you are submitting the report. AMOUNT REQUESTED: This should match the amount on the "TOTAL AMOUNT " line for the "AMOUNT OF THIS CLAIM" column, GRANTEE'S GRANT MANAGER: This should be the person identified as grant manager in the grant agreement. PAYMENT REQUEST NO.: This is the number of your payment request, not the quarter number. PERFORMANCE PERIOD: This is the beginning and ending date of the reporting period. PERCENT MATCHING REQUIRED: Enter your match requirement here, It is either 100% or NIA for Section 309 grants. GRANT EXPENDITURES SUMAIAR Y SECTION. "AMOUNT OF THIS CLAIM" COLUMN: Enter the amount that was paid out during the reporting period for each approved budget category. This must be by budget category as in the currently approved budget in Attachment A, Project Work Plan, or amendment of your grant Agreement. Do not claim expenses in a budget category that does not have an approved budget. Do not claim items that are not specifically identified in the current Budget Narrative section of Attachment A. DO NOT ALTER FORM OR COMBINE BUDGET CATEGORIES. Enter the column total on the "TOTAL AMOUNT' line. Enter the FCMP budget amount on the "GRANT BUDGET AMOUNT' line, Enter the total cumulative amount of this request and all previous payments on the "LESS TOTAL CUMULATIVE PAYMENTS OF" line. Deduct the "LESS TOTAL CUMULATIVE PAYMENTS OF' from the "GRANT BUDGET AMOUNT" for the amount to enter on the "REMAINING BUDGET IN GRANT" line. "TOTAL CUMULATIVE FCMP CLAIMS" COLUMN: Enter the cumulative amounts that have been claimed to date for FCMP expenses by budget category. The final report should show the total of all claims, first claim through the final claim, etc. Enter the column total on the "TOTAL AMOUNT' line, DO NOT ENTER ANYTHING IN THE SHADED AREAS. "MATCHING FUNDS CLAIMED" COLUMN: Enter the amount to be claimed as match for the reporting period. This needs to be shown under specific budget categories according to what is in the currently approved Attachment A, Project Work Plan, Enter the total on the "TOTAL AMOUNT' line for this column. Enter the match budget amount on the "GRANT BUDGET AMOUNT' line for this column. Enter the total cumulative amount of this and any previous match claimed on the "LESS TOTAL CUMULATIVE PAYMENTS OF' line for this column. Deduct the "LESS TOTAL CUMULATIVE PA YMENTS OF' from the "GRANT BUDGET AMOUNT' for the amount to enter on the "REMAINING BUDGET IN GRANT' line. "TOTAL CUMULATIVE MATC14ING FUNDS" COLUMN, Enter the cumulative amount you have claimed to date for match by budget category. Put the total of all on the line titled "TOTAL AMOUNT." The final report should show the total of all claims, first claim through the final claim, etc. DO NOT ENTER ANYTHING IN THE SHADED AREAS. GRANTEE CERTIFICATION: Must have the original signature of both the Grantee's Grant Manager and the Grantee's Fiscal Agent as identified in the grant agreement. DEP .Agreement No. CZ613, Attachment C, Page 2 of 3 REQUIRED BACK-UP DOCUMENTATION; Schedule of Expenditures should include, the invoice number, a description of the goods or services purchased, date of the transaction, amount paid, check amount, check number and vendor name. Schedule of Match should include, the invoice number, a description of the goods or services purchased, date of the transaction, amount paid, check amount, check number and vendor name. Copies of Invoices (1Vot applicable to state agencies) Copies of Travel Reimbursements if applicable FLAIR Report (State agencies on1j) NOTE: If claiming reimbursement for travel, you must include copies of receipts and a copy of the travel reimbursement form (available from staff of the Florida Coastal Management Program or use your affiliation's reimbursement form, provided it has been approved by the State of Florida Chief Financial Officer). **DO NOT FORGET TO SUBMIT A COMPLETED PROGRESS REPORT IN CONJUNCTION WITH YOUR PAYMENT REQUEST** If you have any questions please do not hesitate to contact Leeanne Zimmerman at (850) 245-2164. DEP Agreement No. CZ613, Attachment C, Page 3 of 3