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ATTACHMENT B <br /> PAYMENT REQUEST SUMMARY FORM <br /> Grantee : Grantee' s Grant Manager. <br /> Mailing Address : <br /> Payment Request No. : <br /> DEP Agreement No. . <br /> Date Of Request: Performance <br /> Period : <br /> Task/Deliverable Amount Task/Deliverable <br /> Requested : $ No. <br /> GRANT EXPENDITURES SUMMARY SECTION <br /> Effective Date of Grant throu h End-of--Grant Period <br /> AMOUNT OF TOTAL MATCHING TOTAL <br /> CATEGORY OF EXPENDITURE THIS REQUEST CUMULATIVE FUNDS CUMULATIVE <br /> PAYMENT MATCHING <br /> REQUESTS FUNDS <br /> Salaries $N/A $N/A $N/A $N/A <br /> Fringe Benefits $N/A $N/A $N/A $N/A <br /> Travel (if authorized) . $N/A $N/A $N/A $N/A <br /> Subcontracting. <br /> Design and Permitting $N/A $N/A $ $ <br /> Monitoring $ $ $ $ <br /> Construction $ $ $ $ <br /> Contractual Services $N/A" $N/A $ $ <br /> Supplies/Other Expenses $N/A $N/A $N/A $N/A <br /> Land $N/A $N/A $N/A $N/A <br /> Indirect $N/A $N/A $N/A $N/A <br /> TOTAL AMOUNT $ $ $ $ <br /> TOTAL TASK/DELIVERABLE $ $ <br /> BUDGET AMOUNT <br /> Less Total Cumulative Payment $ $ <br /> Requests oh <br /> TOTAL REMAINING IN TASK $ $ <br /> GRANTEE CERTIFICATION <br /> The undersigned certifies that the amount being requested for reimbursement above <br /> was for items that were charged to and utilized only for the above cited 02t activities . <br /> Grantee's Grant Manager's Signature Grantee's Fiscal Agent <br /> Print Name Print Name <br /> Telephone Number Telephone Number <br /> DEP 55=223 (03/ 12) <br /> DEP Agreement No. G0353 , Attachment B , Page 1 of 2 <br /> C <br />