2010-023 - Laserfiche WebLink

Home Browse Search

FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM REQUEST FOR PAYMENT — PART II REIMBURSEMENT DETAIL Name of Project: Billing# Billing Period : DEP CONTRACT NUMBER Invoice Adjustments (To be completed by DEP : Grantee : Reasons for changes noted below) Date OF Amount Paid Eligible Total Amount Changes per p BBCS Changes per g p BBCS Approved Item # Invoice # Project sowiBiD # (3) Vendor Name Check or Debit# Eligible for State INVOICE Vendor ( 1 ) Item (2) Share (4) Project Manager (5,6) Accountant (5,6) Eligible Cost (b) 1 2 3 4 5 6 7 8 9 10 Totals for all items on page : Item # Notes and invoice adjustment explanations per item # (5) Certification : I certify that the purchases noted above were used in accomplishing the project; and that invoices, check vouchers, copies of checks, and other purchasing documentation are maintained as required to support the cost reported above and are available for audit upon request. Name/Signature of Project Administrator Date Name/Signature of Project Financial Officer Date Form Instructions: ( 1 ) Grantee: enter exact amount of check or debit. (2) Grantee: enter the subtask ID# from the Eligible Project Item table of the DEP Grant. (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. (4) Grantee: insert only the amount of vender payment that is assumed to be eligible for DEP cost share. (5) Grantee: DEP Project Managers and accountants will make necessary corrections or adjustments within the terms of the contract and in accordance with state rule. 6 DEP staff: Enter the total amount of line item increase or decrease : if the adjustment is a decrease , preceed the amount with the "" minus sign . DEP Agreement No . 07182 , Amendment No . 1 , Attachment C - 1 , Page 2 of 3