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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br /> BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br /> CERTICATION OF DISBURSEMENT REQUEST <br /> REQUEST FOR PAYMENT — PART IV <br /> Name of Project : INDIAN RIVER COUNTY HURRICANE REPAIR PROJECT <br /> LOCAL SPONSOR: INDIAN COUNTY DEP Agreement Number: 14IR2 <br /> Billing Number : <br /> Certification : I certify that this billing is correct and is based upon actual obligations of record <br /> by the LOCAL <br /> SPONSOR; that payment from the State Government has not been received; that the work and/or services <br /> are in <br /> accordance with the Department of Environmental Protection, Beach Management Funding Assistance Program ' s <br /> approved Project Agreement including any amendments thereto ; and that progress of the work and/or services <br /> are <br /> satisfactory and are consistent with the amount billed . The disbursement amount requested on Page 1 of this form is for <br /> allowable costs for the project described in the grant work plan . <br /> I certify that the purchases noted were used in accomplishing the project; and that invoices, check vouchers, copies of <br /> checks, and other purchasing documentation are maintained as required to support the cost reported above and are <br /> available for audit upon request. <br /> Name of Project Administrator Signature of Project Administrator Date <br /> Name of Project Financial Officer Signature of Project Financial Officer Date <br /> DEP Agreement No. 14IR2 , Attachment E, Page 4 of 4 <br />