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Attachment C <br />JUSTIFICATION OF ADVANCE PAYMENT <br />RECIPIENT: <br />Indicate by checking one of the boxes below, if you are requesting an advance. If an advance payment <br />is requested, budget data on which the request is based must be submitted. Any advance payment <br />under this Agreement is subject to s. 216.181(16), Florida Statutes. The amount which may be <br />advanced shall not exceed the expected cash needs of the Recipient within the initial three months of <br />the Agreement. <br />[X I NO ADVANCE REQUESTED <br />No advance payment is requested. <br />Payment will be solely on a <br />reimbursement basis. No additional <br />information is required. <br />ADVANCE REQUEST WORKSHEET <br />[ ] ADVANCE REQUESTED <br />Advance payment of $ is requested. Balance of <br />payments will be made on a reimbursement basis. These funds <br />are needed to pay staff, award benefits to clients, duplicate forms <br />and purchase start-up supplies and equipment. We would not be <br />able to operate the program without this advance. <br />If you are requesting an advance, complete the following worksheet <br />First <br />(A) <br />(B) <br />(C) <br />(D) <br />you do <br />FFY <br />FFY <br />FFY <br />Total <br />DESCRIPTION <br />information, call your consultant and he or <br />she will assist you. <br />1 <br />INITIAL CONTRACT ALLOCATION <br />2 <br />FIRST THREE MONTHS CONTRACT <br />EXPENDITURES' <br />3 <br />AVERAGE PERCENT EXPENDED IN FIRST <br />THREE MONTHS <br />(Divide line 2 by line 1.) <br />First <br />three months <br />expenditures neea only ue proviaea Tor the <br />years in wnicn you requestea <br />an aavance. IT <br />you do <br />not <br />have <br />this <br />information, call your consultant and he or <br />she will assist you. <br />MAXIMUM ADVANCE ALLOWED CALULATION: <br />X $ <br />Cell D3 <br />DEM Award <br />(Do not include any match) <br />REQUEST FOR WAIVER OF CALCULATED MAXIMUM <br />MAXIMUM <br />ADVANCE <br />[ ] Recipient has no previous DCA/DEM contract history. Complete Estimated Expenses chart and <br />Explanation of Circumstances below. <br />[ ] Recipient has exceptional circumstances that require an advance greater than the Maximum <br />Advance calculated above. <br />Complete Estimated Expenses chart and Explanation of Circumstances below. Attach additional <br />pages if needed. <br />30 <br />