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Name of Project: <br />Billing Number. <br />DEP Agreement Number <br />FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REVISED REQUEST FOR PAYMENT — PART II <br />Billing Period (1)• <br />Person Completing Form & Telephone Number (2)• <br />REIMBURSEMENT DETAIL <br />Item t$Number <br />Vendor <br />Name <br />Invoice <br />Namber <br />Check <br />Number <br />Deliverable <br />(3) <br />Eligible <br />Cost <br />(4) <br />% <br />Fed <br />Shareaa <br />Federal <br />Share <br />of <br />Invoice <br />Amount <br />(fat <br />Non- <br />Federal <br />Share <br />(7) <br />% <br />State <br />Share <br />(8)(9) <br />State <br />Share <br />Local <br />Share <br />(10) <br />Retainage <br />Payment <br />(11) <br />Withheld <br />Retainage <br />(12) <br />State <br />Payment <br />(13) <br />- <br />- <br />50.00 <br />0.00 <br />0.00 <br />0.00 <br />Sub -Totals: <br />- <br />- <br />- <br />- <br />Total Due to Local Sponsor (14) <br />Form Instnxiions: <br />1. Blling Period: Should reflect Invoice servibea performed daze. (beginning date - earliest date of services, end date - latest date of services performed). <br />2. Poison to Contact for questions regarding ?ferns submitted on this form. <br />3. Delrveable d: Must identity completed de iverable(s) for each invoice. If invoice coven multiple deliverables, that invoice would be listed multiple times, a IncIitem for each deliverable <br />4. Eligible Cast: Invoico amount paid by Local Sponsor less ineligible cost far Line Item Deliverable only. <br />5. %Federal Stare: If applicable this sharldbe the percentage listed in Agreement. Federal Share will be listed on Table I if applicable. <br />6. Federal Share If applicable, Local Sporuawiill multiply Etigibk Cost by Federal Share Percentage. <br />7. Non -Federal Share: Eligible Cost (4) minis Federal Share of Invoiced Amount (6). <br />8. Percentage of State Sham: Thu should be Inc State Share Percentage listed in Agreement <br />9. StatieShare: Multiply Non -Federal Share by State Share Percentage. <br />10. Local Share: Subtrect State Sham from Non -Federal Share. <br />11. Retaj nage Payment Requires separate liner for each completed Task, Sub -Task and or Deliverable that retabrage is being requested. <br />12. Withheld Retainage: Multiply State Share by 10%. <br />13. State'Paymait Subtract Retainage from State Share, <br />14. Total Due to Local Sponsor: Md Rctaixiage Payment Total (II) to State Payment Total (13). <br />Notes: For questions or mice= regarding thisl,fonm please canted: Janice Simmons - (850)245-8222 or email at Janice.L.Simmons@dep.state.fl.us <br />DEP Agreement No. 15IR1, Attachment C, Page 2 of 4 <br />