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Grantee: ATTACHMENT B PAYMENT REQUEST SUMMARY FORM Mailing Address: DEP Agreement No.: S0733 Date Of Request: Task/Deliverable Amount Requested:$ Grantee's Grant Manager: Payment Request No.: Performance Period: Task/Deliverable No.: 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 FUNDS TOTAL CUMULATIVE MATCHING FUNDS Salaries $N/A $N/A $N/A $N/A Fringe Benefits $N/A $N/A $N/A $N/A Travel (if authorized) $N/A $N/A $N/A $N/A Subcontracting: Planning $N/A $N/A $N/A $N/A Design $N/A $N/A $N/A $N/A Construction $N/A $N/A $N/A $N/A Equipment Purchases $ $ $ $ Supplies/Other Expenses $N/A $N/A $N/A $N/A Land $N/A $N/A $N/A $N/A Indirect $N/A $N/A $N/A $N/A TOTAL AMOUNT $ $ $ $ TOTAL TASK/DELIVERABLE BUDGET AMOUNT $ $ Less Total Cumulative Payment Requests of: $ $ TOTAL REMAINING IN TASK $ $ GRANTEE CERTIFICATION The undersigned certifies that the amount being requested for reimbursement above was for items that were charged to and utilized only for the above cited grant activities. Grantee's Grant Manager's Signature Grantee's Fiscal Agent Print Name Print Name Telephone Number Telephone Number DEP 55-223 (03/12) DEP Agreement No. S0733, Attachment B, Page 1 of 2 85