HomeMy WebLinkAboutExhibit 23ATTACHMENT F
ADVANCE PAYMENT ]USTIFICATON FORM
rse of this form is not required unless the advance requested requires the prior approval of the Comptroller. For advance
equests 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 LP6703
commrMritties/Servicesi ar0)ect Deseripticn;
4 • - .. ..
•
Organizational Structure
jl.e. local gov't non-profit corporation, etc.)
,
Value of Purchase or Grant:
Advance Payment Amount Requested:
Period Advance Payment to Cover:
❑ 90 days startup i full Contract Period
Quarterly I 0 Otherjs ecity):
Indicate Statutory Authority:
B 215.422, F.S
In 216.181, F.S.
GAA Year and Line Item Info:
SFY: 1
Line Rem: !
2. Reason advance payment is required:
2. The following information required for advances requested pursuant to 215.422, Florida Statues
(and the Comptroiler'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. ]n calculating the percent savings es 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 Agreement No.1,P6703 , Attachment F, Pape I of
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. (Lirnited to GAA Authorized, Statutorily Authorised, and Grant S Aid
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_for_warded 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. 1.P6703, Attachment F, Page 2 of 3
3. The recipient muss 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
First Quarter
Second
Quarter
Third Quarter
Fourth Quarter
Salaries
(identify personnelLtitles)
Fringe Benefits
Contractual Services
(list services and estimated
costs)
Equipment
(identify each Item and cost)
Supplies
Travel
Other �spectfy)
�..._
�_ • w
:fl..eehaae IPMCI Pef
I
Total:
Certification Statement
The forgoing information is presented to the Florida Department of Environmental Protection in support of our
- request for advance payment. 1 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
Date
DEP Program Area Review/Approval
Recommendation;
0 Approve Request 0 Deny Request
By:
Type Name of Signatory:
Title'
Bureau: Division:
Date
The DEP Program Area should forward this information to the Contracts Disbursements Section at M578. 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. t.P6703 • Attachment F, Page 3 of 3