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A TRUE COPY <br />CERTIFICATION ON LAS1 Pai, <br />ATTACHMENT B J.R. SMITH, CLERK <br />PAYMENT REQUEST SUMMARY FORM <br />Grantee: <br />Mailing Address: <br />DEP Agreement No.: S0733 <br />Date Of Request: <br />Task/Deliverable Amount <br />Requested:$ <br />Grantee's Grant Manager: <br />Payment Request No.: <br />Performance <br />Period: <br />Task/Deliverable <br />No.. <br />GRANT EXPENDITURES SUMMARY SECTION <br />MRpt-tiue T)ntP of (;rant thrnnoh Fnd-nf-Grant Period] <br />CATEGORY OF EXPENDITURE <br />AMOUNT OF <br />THIS REQUEST <br />v TOTAL <br />CUMULATIVE <br />PAYMENT <br />REQUESTS <br />MATCHING <br />FUNDS <br />TOTAL <br />CUMULATIVE <br />MATCHING <br />FUNDS <br />Salaries <br />$N/A <br />$N/A <br />SN/A <br />$N/A <br />Fringe Benefits <br />SN/A <br />$N/A <br />$N/A <br />$N/A <br />Travel (if authorized) <br />$N/A <br />$N/A <br />$N/A <br />$N/A <br />Subcontracting: <br />Planning <br />$N/A <br />$N/A <br />$N/A <br />$N/A <br />Design <br />$N/A <br />$N/A <br />$N/A <br />$N/A <br />Construction <br />$N/A <br />$N/A <br />$N/A <br />$N/A <br />Equipment Purchases <br />$ <br />$ <br />$ <br />$ <br />Supplies/Other Expenses <br />$N/A <br />$N/A <br />$N/A <br />$N/A <br />Land <br />$N/A <br />$N/A <br />$N/A <br />$N/A <br />Indirect <br />$N/A <br />$N/A <br />SN/A <br />$N/A <br />TOTAL AMOUNT <br />S <br />$ <br />S <br />$ <br />TOTAL TASK/DELIVERABLE <br />BUDGET AMOUNT <br />S <br />$ <br />$ <br />Less Total Cumulative Payment <br />Requests of: <br />$ <br />TOTAL REMAINING IN TASK <br />$ <br />$ <br />GRANTEE CERTIFICATION <br />The undersigned certifies that the amount being requested for reimbursement above <br />was for items that were charged to and utilized <br />Grantee's Grant Manager's Signature <br />Print Name <br />Telephone Number <br />DEP 55-223 (03/12) <br />DEP Agreement No. S0733, Attachment 13, Page 1 of 2 <br />for the above cited grant activities. <br />Grantee's Fiscal Agent <br />Print Name <br />Telephone Number <br />