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INSTRUCTIONS FOR COMPLETING PAYMENT REQUEST SUMMARY FORM DEP AGREEMENT NO.: This is the number on your grant agreement. AGREEMENT EFFECTIVE DATES: Enter agreement execution date through end date. GRANTEE: Enter the name of the grantee's agency. GRANTEE'S GRANT MANAGER: This should be the person identified as grant manager in the grant Agreement. MAILING ADDRESS: Enter the address that you want the state warrant sent. PAYMENT REQUEST NO.: This is the number of your payment request,not the quarter number. DATE OF PAYMENT REQUEST: This is the date you are submitting the request. PERFORMANCE PERIOD: This is the beginning and ending date of the performance period for the task/deliverable that the request is for(this must be within the timeline shown for the task/deliverable in the Agreement). TASK/DELIVERABLE NO.: This is the number of the task/deliverable that you are requesting payment for and/or claiming match for(must agree with the current Grant Work Plan). TASK/DELIVERABLE AMOUNT ,REQUESTED: This should match the amount on the "TOTAL TASKIDELIVERABLE BUDGET AMOUNT"line for the"AMOUNT OF THIS REQUEST'column. GRANT EXPENDITURES SUMMARY SECTION: "AMOUNT OF THIS REQUEST"COLUMN: Enter the amount that was expended for this task during the period for which you are requesting reimbursement for this task. This must agree with the currently approved budget in the current Grant Work Plan of your grant Agreement. Do not claim expenses in a budget category that does not have an approved budget. Do not claim items that are not specifically identified in the current Grant Work Plan. Enter the column total on the"TOTAL AMOUNT'line. Enter the amount of the task on the"TOTAL TASKBUDGETAMOUNT' line. Enter the total cumulative amount of this request and all previous payments on the"LESS TOTAL CUMULATIVE PAYMENT REQUESTS OF' line. Deduct the "LESS TOTAL CUMULATIVE PAYMENT REQUESTS OF' from the "TOTAL TASKBUDGETAMOUNT'for the amount to enter on the"TOTAL REMAINING IN TASK" line. "TOTAL CUMULATIVE PAYMENT REQUESTS" COLUMN: Enter the cumulative amounts that have been requested to date for reimbursement by budget category. The final request should show the total of all requests; first through the final request(this amount cannot exceed the approved budget amount for that budget category for the task you are reporting on). Enter the column total on the"TOTALS"line. Do not enter anything in the shaded areas. "MATCHING FUNDS" COLUMN: Enter the amount to be claimed as match for the performance period for the task you are reporting on. This needs to be shown under specific budget categories according to the currently approved Grant Work Plan. Enter the total on the"TOTAL AMOUNT'line for this column. Enter the match budget amount on the `'TOTAL TASK BUDGET AMOUNT' line for this column. Enter the total cumulative amount of this and any previous match claimed on the"LESS TOTAL CUMULATIVE PAYMENTS OF'line for this column. Deduct the"LESS TOTAL CUMULATIVE PAYMENTS OF'from the"TOTAL TASKBUDGETAMOUNT'for the amount to enter on the "TOTAL REMAINING IN TASK"line. "TOTAL CUMULATIVE MATCHING FUNDS" COLUMN: Enter the cumulative amount you have claimed to date for match by budget category for the task. Put the total of all on the line titled"TOTALS." The final report should show the total of all claims,first claim through the final claim,etc. Do not enter anything in the shaded areas. GRANTEE'S CERTIFICATION: Check all boxes that apply. Identify any licensed professional service providers that certified work or services completed during the period included in the request for payment. Must be signed by both the Grantee's Grant Manager as identified in the grant agreement and the Grantee's Fiscal Agent. NOTES: If claiming reimbursement for travel,you must include copies of receipts and a copy of the travel reimbursement form approved by the Department of Financial Services,Chief Financial Officer. Documentation for match claims must meet the same requirements as those expenditures for reimbursement. DEP 55-223(11/15) DEP Agreement No.S0839,Attachment B,Page 3 of 3