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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REVISED REQUEST FOR PAYMENT — PART II <br />Name of Project: <br />Billing# <br />DEP AGREEMENT NUMBER <br />Billing Period: (1) <br />Person Completing Form <br />Telephone Number <br />^_• <br />Item <br /># <br />Vendor Name <br />Invoke <br />Number <br />Invoice <br />pate <br />Check <br />Number <br />Deliverable <br />Numbers) <br />Eligible Cost <br />(4) <br />/Fed <br />Share (5) <br />Federal Share <br />of Invoice <br />Amount (6) <br />Non -Federal <br />%State <br />Share (8) <br />State Share (9) <br />State(7) <br />Local Share <br />(10) <br />Ratainag <br />e <br />Payment <br />(11) <br />Withheld <br />Retainage <br />(72) <br />State Payment <br />(13) <br />Totals: <br />Total Due to Local Sponsor (14) <br />Form Instructions: <br />1 <br />Billing Period: Should reflect Invoice services performed date. ( beginning date - earliest date of services, end date - latest date of services performed. <br />2 <br />Penton to Contact for questions regarding Items submitted on thls form. <br />3 <br />Deliverable #: Must identify completed deliverable(s) for each invoice. If invoice covers multiple deliverables, that invoice would be listed multiple times, a line item for each deliverable. <br />4 <br />Eligible Cost Invoice amount paid by Local Sponsor less ineligible cost for Line Item Deliverable only. <br />5 <br />% Federal Share: If applicable this should be the percentage listed in Agreement. Federal Share will be listed on lable 1 if applicable. <br />6 <br />Federal Share: If applicable, Local Sponsor will multiply Eligible Cost by Federal Share Percentage. <br />7 <br />Non -Federal Share: Eligible Cost (4) minus Federal Share of Invoiced Amount (6) <br />8 <br />Percentage of State Share: This should be the State Share Percentage listed in Agreement <br />State Share: Multiply Non -Federal Share by State Share Percentage. <br />9 <br />10 <br />Local Share: Subtract State Share from Non -Federal Share <br />11 <br />Retainage Payment: Requires separate line for each completed Task, Sub -Task and or Deliverable that retai <br />nage is being requested. <br />12 <br />Withheld Retainage: Multiply <br />State Share b 10% <br />from State Share <br />13 <br />State Payment: Subtract Retainage <br />14 <br />Total Due to Local Sponsor: Add Retainage Payment Total to State Payment Total. <br />Notes: <br />For questions or concerns regarding this form please contact: Janice Simmons - (850)245-8222 or email at Janice.LSimmons@dep.state.fl.us <br />DEP Agreement No. 14182, Amendment No. 1, Attachment E-1, Page 2 of 4 <br />