HomeMy WebLinkAboutExhibit 9ATTACHMENT C
PAYMENT REQUEST FORAM
GRANTEE: GRANTEE'S GRANT MANAGER:
DEP AGREEMENT NO.:
DATE OF REQUEST:
AMOUNT REQUESTED:$
PAYMENT REQUEST NO.:
PERFORMANCE
PERJ OD:
PERCENT MATC
tG
QUIRED:
GRA T i XPENDITUMARY ECTjON
(Effective Date of Gran through End -of -Grant Period)
TOTAL
CUMULATIVE
FCMP
CLAJMS
Supplies
Contractual Services
Construction
AWNING 8 UDGET IN GRANT 15
GRANTEE CERTIFICATION
The undersigned ccnilics. that the amount bring requested for reimbursement above
was for items that were charged io and utilized only for the above cited grant activities.
Grantee's Grant Manager's Signature Grantee's Fiscal Agent
Print Name
Print Name
l Telephone Number Telephone Number
••PLEASE DO NOT ALTER THIS FORM ••
TOTAL.
CUMULATIVE
MATCHING
FUNDS
DEP Agreement No. CZ613, Alta chrrlent C; Page J of 3
INSTRUCTIONS FOR COMPLETING
• ATTAl�HMENT C
PAYMENT BEQUEST FORM
GRANTEE: Enter the name of the grantee's agency. ,
DE P 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.
1
AMOUNT REQUESTED: This should match the amohnt on the "TOTAL AMOUNT" Iine for the "AMOUAV'OF
THIS CLAIM" column.
GRANTEE'S GRANT MANAGER: This should be Iye person identified as grant manager in the grant agreement.
PAYMENT REQUEST NO.: Thus is the number of yoir payment request, not the quaver number.
PERFORMANCE PERIOD: This is the beginning and; ending dale of the reporting period.
PERCENT MATCHING REQUIRED; Enter your march requirement here. It is either P00% or NIA for Section
309 grants.
QR.ANT EXPENDITURES SUMMAR J'SECTION:
"AMOUNT OF THIS CLAIM" COLUMN: Enter the amount that was paid out during the reponing period for
each approved budget category. This must be by budget category as in the current?), approved budget in A nach meet
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 sterns that are not specifically identified sn the current Budget
Narrative section o(Anarlimcnt 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 thislrequest and all previous payments on the "LESS TOTAL
CUM ULAT/PE PA YMENTS OF' line. Deduct the "LESS TOTAL CUMULAT/VL PAYMENTS OF' from the
"GRANT BUDGET AMOUNT' for the amount to enter on ;he "REMAINING BUDGET IN GRANT' line.
"TQTAL CUMULATIVE FCMP CLAIMS" COLUMN; Enter the cumulative amounts that have been claimed
to dale for FCMP expenses by budget category. The final report should show the total of all claims, first claim
throughthe 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
Anachmcnl A, Project Work Plan. Enter the total on the "TOTAL AMOUNT' line for this column. Enter the match
budget amount on the "GRANT BUDGE T 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 PAYMENTS OF1 from the "GRANT BUDGET AMOUNT' for the amount
to enter on the "REMAINING BUDGET /N GRAA'T' line.
"TOTAL CUMULAT[YE 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 tenon should
show the total of all claims, first claim Through the final claim, etc. DO NOT ENTER ANYTHING IN THE
SHADED AREAS.
GRANTEE CERTIFICATION: JFICATION: Must have the original signature of both the Grantee's Grant Manager and
the Grantee's Fiscal Agent as identified in the grant agreement.
DER Agreement No, CZ6t3, Attachment C, Page 2 of 3
REQUIRED BACKUP DOCUMENTATION: ,
Schedule of Expenditures should include, the invoice dumber, o 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 ofthe
transaction, amount paid, chcck amount, check number ind vendor name.
Copies of Invoices (Not applicable to ,stair agencies)
Copies of Travel Reimbursements if applicable
•
FLAIR Report (Slone agencies only)
NOTE: If claiming reimbursement for travel, you mist include copies of receipts and a copy of the travel
reimbursement form (available front staff of the Florl(da Coastal Alanegemenr Program or use your
affiliation's reimbursement form, provided it has beer) approved by the State of Florida Chief Financial
Officer).
DO NOT FORCET TO SUBMT ACOMPLETEI)IPROGRESSREPORT INCONJUNCTION
YOUR PAYMENT REQUEST••
If you have any questions please do not hesitate to contact L Leanne Zimmerman at (8S0) 2lS-2164.
DEP ARreemrn(No. CZ61J, Attachment C, Page 3 of 3