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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />CERTIFICATION OF DISBURSEMENT REQUEST <br />REQUEST FOR PAYMENT — PART IV <br />NAME OF PROJECT: INDIAN RIVER COUNTY HURRICANE REPAIR PROJECT <br />LOCAL SPONSOR: INDIAN RIVER COUNTY <br />DEPARTEMENT Agreement Number: 14IR2 <br />Billing Number: <br />Certification: I certify that this billing is correct and is based upon actual obligations of record by the LOCAL SPONSOR; <br />that payment from the State Government has not been received; that the work and/or services are in accordance with the <br />Department of Environmental Protection, Beach Management Funding Assistance Program's approved Project Agreement <br />including any amendments thereto; and that progress of the work and/or services are satisfactory and are consistent with the <br />amount billed. The disbursement amount requested on Page 1 of this form is for allowable costs for the project described <br />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 available <br />for audit upon request. <br />Name of Project Administrator <br />Name of Project Financial Officer <br />Signature of Project Administrator Date <br />Signature of Project Financial Officer Date <br />DEP Agreement No. 141R2, Amendment No. 2, Attachment C, Page 5 of 5 <br />115 <br />