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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 First Quarter Second Third Quarter Fourth Quarter <br /> Quarter <br /> Salaries <br /> (identify person nel 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 ReviewZApproval <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 55-222 (03-02) <br /> DEP Agreement No. LP6734, Attachment F, Page 3 of 3 <br />