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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br /> BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br /> REQUEST FOR PAYMENT — PART II <br /> REIMBURSEMENT DETAIL <br /> Name of Project: Billing# Billing Period : DEP CONTRACT NUMBER Invoice Adjustments (To be completed by DEP: <br /> Grantee: Reasons for changes noted below) <br /> Date OF Amount Paid Eligible Total Amount Chan aserBBCS Chan es erBBCS <br /> Item # INVOICE Invoice # Vendor (1 ) Project apw(61D # (s) Vendor Name Check or Debit# Eligible for State g p 9 P Approved <br /> Item (2) Share (4) Project Manager (6,6) Accountant (6,6) Eligible Cost (6) <br /> 7 <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> Totals for all Items on pageJ <br /> Item # Notes and invoice adjustment explanations per item # (5) <br /> Certification: I certiry that the purchases noted above were used in accomplishing the project; and that invoices, check vouchers, copies of checks, and other purchasing <br /> documentation are maintained as required to <br /> support the cost reported above and are available for audit upon request- <br /> Name/Signature of Project Administrator Date <br /> Name/Signature of Project Financial Officer Date <br /> Form Instructions: <br /> (1 ) Grantee: enter exact amount of check or debit. <br /> (2) Grantee. enter the subtask ID# from the Eligible Project Item table of the DEP Grant. <br /> (3) Scopes of work and bids that have been approved for DEP cost share may be assigned a tracking identifier number. Grantee: Insert this tracking number when applicable. <br /> (4) Grantee: insert only the amount of vender payment that is assumed to be eligible for DEP cost share. <br /> Grantee: DEP Projthect Managers and accountants will make necessary corrections or adjustments within the terms of the contract and in accordance with state rule. <br /> (5j <br /> 6 DEP stall: Enter e total amount of line item increase or decrease: if the adjustmentis a decrease, eneceed the amount with the "-" minus sign. <br /> DEP Agreement No. 071R1 , Attachment C, Page 2 of 3 <br />