Laserfiche WebLink
ATTACHMENT B <br /> PAYMENT REQUEST SUMMARY FORM <br /> DEP Agreement No.: Agreement Effective Dates: <br /> Grantee: Grantee's Grant Manager: <br /> Mailing Address: <br /> Payment Request No. Date of Payment Request: <br /> Performance Period (Start dare—End dare): <br /> Task/Deliverable No(s). Task/Deliverable Amount Requested: $ <br /> GRANT EXPENDITURES SUMMARY SECTION <br /> [Effective Date of Grant through End-of-Grant Period] <br /> AMOUNT OF TOTAL MATCHING TOTAL <br /> CATEGORY OF EXPENDITURE THIS REQUEST CUMULATIVE FUNDS FOR CUMULATIVE <br /> PAYMENT THIS REQUEST MATCHING <br /> REQUESTS FUNDS <br /> Salaries/Wages $ $ $ $ <br /> Overhead/Indirect/G&A Costs $ $ $ $ <br /> Fringe Benefits $ $ $ $ <br /> Indirect Cost $ $ $ $ <br /> Contractual(Subcontractors) $ $ $ $ <br /> Travel(if authorized) $ $ $ $ <br /> Equipment Purchases(if authorized) $ $ $ $ <br /> Rental/Lease of Equipment $ $ $ $ <br /> Other Expenses $ $ $ $ <br /> Land(if authorized) $ $ $ $ <br /> TOTAL AMOUNT $ $ $ $ <br /> TOTAL TASK/DELIVERABLE $ $ <br /> BUDGET AMOUNT <br /> Less Total Cumulative Payment $ $ <br /> Requests of: <br /> TOTAL REMAINING IN TASK $ $ <br /> GRANTEE CERTIFICATION <br /> Complete Grantee's Certification of Payment Request on Page 2 to certify that the amount being <br /> requested for reimbursement above was for items that were charged to and utilized only for the above <br /> cited grant activities. <br /> DEP 55-223(11/15) <br /> DEP Agreement No.S0839,Attachment B,Page 1 of 3 <br />