HomeMy WebLinkAboutExhibit 4ATTACHMENT B
GRANT PAYMENT/MATCH REQUEST
Grant Number: F0921
City of Miami LE638 CVA 07-480
(GRANTEE) (Project Agreement No) (Application No.)
DEP Division: Law Enforcement DEP Program: Clean Vessel Program
Billing Date: Billing No,:
Payment Requested? Match Credit Requested? Yes No
If Department payment is being requested, an invoice on your letterhead must accompany this form.
DEPARTMENT GRANTEE
(75°) Payment (25%) Match
Permitting $ $
Construction
Renovation
Equipment Purchase
=2;quipment Installation
)perations and Maintenance
nformation (signs, brochures)
'sducation and Instruction
TOTAL $ $
-2ertification and Attestation: I certify that documentation has been and will be maintained as required by the
►greement to support the amounts reported above and is available for audit upon request. I attest that all expenditures
rior to this request have been made and are true and accurate and are only for the purposes as described in the Clean
7essel Act Grant Project LE638. I further attest, under the penalties of perjury, that (name of the marina or entity)
has complied with the provisions of the grant.
FOTARY PUBLIC: Subscribed and sworn
.efore me at
Grantee's Project Manager/Attestor
his day of
itle} Date
(Seal)
�P 55-240 (12/05)
:P Agreement No. LE638, Attachment B, Page 1 of 1