HomeMy WebLinkAboutExhibit 10ATTACHMENT C
PAYMENT REQUEST FORM
GRANTEE: GRANTEE'S GRANT MANAGER;
DEP AGREEMENT NO.:
DATE OF REQUEST:
AMOUNT REQUESTED:$
PAYMENT REQUEST NO.:
PERFORMANCE
PERIOD,
PERCENT MATCHING REQUIRED:
GRANT EXPENDITURES SUMMARY SECTJ2
(Effective Date of Grant through End -of -Grant Period]
AMOUNTCF TOTAL
CATEGORY OF EXPENDITURE THIS CLAIM CUMULATIVE
FCAI P
CLAIMS
Salaries
Fringe Benefits
Travel
Equipment Purchases
Supplies
Contractual Services
Construction
Other Expenses
Indirect
TOTAL AMOUNT
GRANT BUDGET AMMOUNT
Less Total Cwmularive Payments of
REMAINING B UD GET IN GRANT
S
5
S
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
Telephone Number
Print Name
Telephone Number
**PLEASE DO NOT ALTER THIS FORM**
DEP Agreement No• C1613, Attachment Ci Page 1 of 3
S
MATCHINC
FUNDS
CLAIMED
TOTAL
CUMULATIVE
MATCHING
FUNDS
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 subrruning 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 N/A for Section
309 grants.
GRANT EXPENDITURES SUMMARY SECTION:
"AMOUNT OF THIS CLAIM" COLUMN: Enter the amount that was paid out during the reporting period for
each approved budget category. This must he 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 ofAnachment A. DO NOT ALTER FORA! OR COMBINE BUDGET CATEGORIES, Enter
the column total on the "TOTAL AMOUNT' line, Enter the FCMP budget amount on the "GRANT BUDGET
AMOUNT' We. 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 CUM ULATI VE 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
Anachment 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 OP' line for this colurnn.
Deduce 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 MATCHING 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 Agrrement No. C2613, Attachment C, Page 2 of 3