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A TRUE COPY CERTIFICATION ON LAS1 Pai, ATTACHMENT B J.R. SMITH, CLERK PAYMENT REQUEST SUMMARY FORM Grantee: 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 MRpt-tiue T)ntP of (;rant thrnnoh Fnd-nf-Grant Period] CATEGORY OF EXPENDITURE AMOUNT OF THIS REQUEST v TOTAL CUMULATIVE PAYMENT REQUESTS MATCHING FUNDS TOTAL CUMULATIVE MATCHING FUNDS Salaries $N/A $N/A SN/A $N/A Fringe Benefits SN/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 SN/A $N/A TOTAL AMOUNT S $ S $ TOTAL TASK/DELIVERABLE BUDGET AMOUNT S $ $ 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 Grantee's Grant Manager's Signature Print Name Telephone Number DEP 55-223 (03/12) DEP Agreement No. S0733, Attachment 13, Page 1 of 2 for the above cited grant activities. Grantee's Fiscal Agent Print Name Telephone Number