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3. The recipient must provide an estimated budget for each quarter covered by the agreement. The <br />summary information should include salaries, fringe benefits, overhead, contracts (specify services to <br />be contracted out), equipment, if authorized (specify items to be purchased), supplies, travel, and <br />other costs. <br />A sample summary format is provided below. The summary should include the breakdown for each quarter of the <br />agreement period. <br />Description <br />First Quarter <br />Second <br />Third Quarter <br />Fourth Quarter <br />Quarter <br />Salaries <br />(identify personnel <br />titles <br />Fringe Benefits <br />Contractual Services <br />(list services and estimated <br />costs <br />Equipment <br />(identify each item and cost) <br />Supplies <br />Travel <br />Other (specify) <br />Overhead Indirect <br />Total: <br />Certification Statement <br />The forgoing information is presented to the Florida Department of Environmental Protection in support of our <br />request for advance payment. I certify that the information provided accurately reflects the financial <br />issues facing the entity at this time. <br />By: <br />Type Name of Signatory: Date <br />Title: Chief Financial Officer or designee <br />DEP Program Area Review/Approval <br />Recommendation: ❑ Approve Request ❑ Deny Request <br />By: <br />Type Name of Signatory: Date <br />Title: Bureau: Division: <br />The DEP Program Area should forward this information to the Contracts Disbursements Section at MS78. The <br />Contracts Disbursements Section will forward requests for advance payment to the State Comptroller for review <br />and legislature consultation as appropriate. <br />Bureau of Finance & Accounting Use Only <br />DEP <br />55-222 (03-02) <br />DEP <br />Agreement <br />No. <br />LP6822, <br />Attachment F, Page 3 of 3 <br />