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ATTACHMENT B PAYMENT REQUEST SUMMARY FORM DEP Agreement No.: Grantee: Mailing. Address: Payment Request No. Performance Period (Start date — End date): Agreement Effective Dates: Grantee's Grant Manager: Date of Payment Request: Task/Deliverable No(s). Task/Deliverable Amount Requested: $ GRANT EXPENDITURES SUMMARY SECTION [Effective Date of Grant through End -of -Grant Period] CATEGORY OF EXPENDITURE AMOUNT OF THIS REQUEST TOTAL CUMULATIVE PAYMENT REQUESTS MATCHING TOTAL FUNDS FOR CUMULATIVE THIS REQUEST MATCHING FUNDS Salaries/Wages $ $ $ $ Overhead/Indirect/G&A Costs $ $ $ $ Fringe Benefits $ $ $ $ Indirect Cost $ $ $ $ Contractual (Subcontractors) $ $ $ $ Travel (if authorized) $ $ $ $ Equipment Purchases (if authorized) $ $ $ $ Rental/Lease of Equipment $ $ $ $ Other Expenses $ $ $ $ Land (if authorized) $ $ $ $ TOTAL AMOUNT $ $ $ $ TOTAL TASK/DELIVERABLE BUDGET AMOUNT Less Total Cumulative Payment Requests of - TOTAL REMAINING IN TASK $ $ $ $ $ $ GRANTEE CERTIFICATION Complete Grantee's Certification of Payment Request on Page 2 to certify that the amount being requested for reimbursement above was for items that were charged to and utilized only for the above cited grant activities. DEP 55-223 (11/15) DEP Agreement No.S0839, Attachment B, Page 1 of 3 60