HomeMy WebLinkAboutExhibit 21ATTACHMENT F
ADVANCE PAYMENT 3USTIFICATON FORM
Use of this form is not required unless the advance requested requires the prior approval of the Comptroller. For advance
requests that are equal to or less than the purchasing threshold of category two as defined in Section 287.017, Florida
Statutes, and meet one of the advance payment requirements identified in Section 215.422(14), Florida Statutes, use of
this form is waived. However, the purchase requisition or contract review form must clearly identify the criteria being met
under 215.422(14), Florida Statutes that allows the advance to be made without prior Comptroller approval.
Name/Address of the Vendor/Recipient:
Contact Person/Phone No.:
Agreement No./Purchase Order No. (if known):
Commodities/Services/Project Description:
Organizational Structure
(i.e. local gov't, non-profit corporation, etc.)
Value of Purchase or Grant:
Advance Payment Amount Requested:
Period Advance Payment to Cover:
Indicate Statutory Authority:
GAA Year and Line Item Info:
1. Reason advance payment is required:
LP6056
❑ 90 days startup
O Quarterly
❑ 215.422, F.S
SFY:
❑ Full Contract Period
❑ Other (specify):
❑ 216.181, F.S.
Line Item:
2. The following information required for advances requested pursuant to 215.422, Florida Statues
(and the Comptroller's Voucher Processing Handbook) which exceed the purchasing threshold of
category two as defined In 287.017, Florida Statues.
A. Document, if applicable, the cost savings to be incurred as a result of an advance payment that are equal or
greater than the amount the State would earn.by investing the funds and paying in arrears. Include the percent
(%) savings to be realized. In calculating the percent savings as compared to the percent that can be earned by
the State, information may be obtained from the Department of Insurance, Division of Treasury at 850/413-2776
or SunCom 293-2776 regarding the current Treasury earnings rate.
B. Document, if applicable, how the goods or services are essential to the operation of the Department and why
they are available only If advance payment is made:
DEP 55-222 (03-02)
DEP Agreement No. LP6056, Attachment F
ATTACHMENT F
C. Identify the procurement method used to select the vendor.
3. The following information required for advances to Governmental Entities and Non -Profits pursuant
to 216.181, Florida Statutes. (Limited to GAA Authorized, Statutorily Authorized, and Grant & Ald
Appropriation Categories 05XXXX or 14XXXX)
A. The entity acknowledges the requirement to invest advance funds in an interest bearing account and to remit
interest earned to the Department on a quarterly basis.
Provide a description of how the entity intends to invest the advanced funds and track the interest earned on the
advanced funds:
Remittances must: 1) be identified as interest earnings on advances, 2) must identify the applicable DEP
Agreement (or Contract) No., and 3) be forwarded to the following address:
Florida Department of Environmental Protection
Bureau of Finance and Accounting
Receipts Section
P.O. Box 3070
Tallahassee, Florida 32315-3070
B., A letter requesting advance payment from the recipient, on its letterhead, must be attached.
DEP 55-222 (03-02)
DEP Agreement No. LP6056, Attachment F
ATTACHMENT F
3. The recipient must provide an estimated budget for each quarter covered by the agreement. The
summary information should include salaries, fringe benefits, overhead, contracts (specify services to
be contracted out), equipment, if authorized (specify items to be purchased), supplies, travel, and
other costs.
A sample summary format is provided below. The summary should include the breakdown for each quarter of the
agreement period.
Description
Salaries
(identify personnel/titles)
Fringe Benefits
Contractual Services
(list services and estimated
costs)
Equipment
(identify each item and cost)
Supplies
Travel
Other (specify)
Overhead/Indirect
Total:
First Quarter
Second
Quarter
Third Quarter
Fourth Quarter
Certification Statement
The forgoing Information is presented to the Florida Department of Environmental Protection in support of our
request for advance payment. I certify that the information provided accurately reflects the financial
issues facing the entity at this time.
By:
Type Name of Signatory:
Title: Chief Financial Officer or designee
DEP Program Area Review/Approval
Recommendation:
By:
Type Name of Signatory:
Title:
Date
❑ Approve Request 0 Deny Request
Bureau: Division:
Date
The DEP Program Area should forward this information to the Contracts Disbursements Section at MS78. The
Contracts Disbursements Section will forward requests for advance payment to the State Comptroller for review
and legislature consultation, as appropriate.
Bureau of Finance & Accounting Use Only
DEP 55-222 (03-02)
DEP Agreement No. LP6056, Attachment F