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z <br />Q <br />L 7 • f �' <br />FI 0 <br />as <br />aV <br />Q z <br />W - <br />zr <br />• d <br />—z <br />z A <br />o F <br />W <br />2 <br />o�C< <br />az <br />d <br />pU <br />CLw <br />Person Completing Form & I <br />Telephone Number <br />State Payment <br />(13) <br />u`q <br />d <br />Form Instructions: <br />Billing Period: Should reflect Invoice services performed date. ( beginning date - earliest date of services, end date - latest date of services performed. <br />Person to Contact for questions regarding Items submitted on this form. <br />Deliverable IF: Must Identify completed deliverable(s) for each invoice. If invoice covers multiple deliverables, that invoice would be listed multiple times, a line item for each deliverable. <br />Eligible Cost Invoice amount paid by Local Sponsor fess ineligible cost for Line Item Deliverable only. <br />I% Federal Share: If applicable this should be the percentage listed in Agreement. Federal Share will be listed on Table 1 if applicable. <br />Federal Share: If applicable, Local Sponsor will multiply Eligible Cost by Federal Share Percentage. <br />Non -Federal Share: Eligible Cost (4) minus Federal Share of Invoiced Amount (6) <br />Percentage of State Share: This should be the State Share Percentage listed in Agreement <br />State Share: Multiply Non -Federal Share by State Share Percentage. <br />Local Share: Subtract State Share from Non -Federal Share <br />Retainage Payment: Requires separate line for each completed Task, Sub -Task and or Deliverable that retainage is being requested. <br />Withheld Retainage: Multiply State Share by SO% <br />State Payment: Subtract Retainage from State Share <br />Total Due to Local Sponsor: Add Retainage Payment Total to State Payment Total. <br />N <br />z <br />For questions or concerns regarding this form please contact: Janice Simmons - (850)245-8222 or email at Janice.L.Simmons@dep.state.fi.us <br />O Ip N <br />L C <br />3 o <br />f,, <br />a �,.. <br />it <br />s�>vq <br />m C <br />c O—% <br />- <br />iFgjfi <br />Billing Period: (1) <br />Local Share <br />(10) <br />J„S <br />r6ti <br />01. <br />State Share (9) <br />jt4 <br />i <br />FFF L((�� <br />. <br />%State <br />Share (8) <br />fw <br />(,1j.4t� <br />T�I <br />�~�15� <br />DEP AGREEMENT NUMBER <br />Non -Federal <br />Share (7) <br />Federal Share <br />of Invoice <br />Amount (6) <br />%Fed <br />Share (6) <br />07 <br />qt <br />C2v <br />so <br />.... <br />3.Tt=.r,. <br />Name of Project: <br />Deliverable <br />Number (3) <br />Check <br />Number <br />:cF.S4 <br />J'' <br />hT <br />4 <br />O <br />Y <br />xJ <br />J <br />ty4,4A; <br />Invoice <br />Number <br />Ni. <br />M.'? <br />C <br />E <br />V 4k <br />N <br />N <br />M <br />In <br />lO <br />f, <br />CO <br />01 <br />N <br />N <br />M <br />DEP Agreement No. 14IR2, Amendment No. 1, Attachment E-1, Page 2 of 4 <br />105 <br />