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I, <br />on behalf of <br />Grantee's Certification of Payment Request <br />(Print name of Grantee's Grant Manager designated in the Agreement) <br />(Print name of Grantee/Recipient) <br />do hereby certify that: <br />0 The disbursement amount requested is for allowable costs for the project described in Attachment A of <br />the Agreement. <br />0 All costs included in the amount requested have been satisfactorily purchased, performed, received, and <br />applied toward completing the project; such costs are documented by invoices or other appropriate <br />documentation as required in the Agreement. <br />0 The Grantee has paid such costs under the terms and provisions of contracts relating directly to the project; <br />and the Grantee is not in default of any terms or provisions of the contracts. <br />Check all that apply: <br />❑ All permits and approvals required for the construction, which is underway, have been obtained. <br />❑ Construction up to the point of this disbursement is in compliance with the construction plans and permits. <br />❑ The Grantee's Grant Manager relied on certifications from the following professionals that provided <br />services for this project during the time period covered by this Certification of Payment Request, and such <br />certifications are included: <br />Professional Service Provider (Name / License No.) Period of Service (mm/dd/yy — mm/dd/yy) <br />Grantee's Grant Manager's Signature <br />Print Name <br />Telephone Number <br />DEP 55-223 (11/15) <br />DEP Agreement No.S0839, Attachment B, Page 2 of 3 <br />Grantee's Fiscal Agent <br />Print Name <br />Telephone Number <br />61 <br />