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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REVISED REQUEST FOR PAYMENT — PART H <br />Name of Project: WABASSO BEACII RESTORATION PROJECT Billing Period (1): <br />Billing Number: <br />DEP Agreement Number : 141R3 <br />Person Completing Form & Telephone Number (2): <br />REIMBURSEMENT DETAIL <br />Item <br />4 <br />Vendor <br />Name <br />Invoice <br />Number <br />Invoice <br />Date <br />Check <br />Number <br />Deliverable <br />Number (3) <br />Eligible <br />Cost <br />(4) <br />% Fed <br />Share <br />(5) <br />Federal <br />Share of <br />Invoice <br />Amount (6) <br />Non- <br />Federal <br />Share (7) <br />% State <br />Share (8) <br />State <br />Share <br />(9) <br />Local <br />Share (10) <br />Retainage <br />Payment <br />(11) <br />Withheld <br />Retainage <br />(12) <br />State <br />Payment <br />(13) <br />7 <br />Totals - <br />Total Due to Local Sponsor (14) <br />Form Instructions: <br />1. Billing Period: Should reflect Invoice services performed date. (beginning date - earliest date of services, end date - latest date of services performed). <br />2. Person to Contact for questions regarding items submitted on this form. <br />3. Deliverable 4: 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 />4 Eligible Cost: Invoice amount paid by Local Sponsor less ineligible cost for Line Item Deliverable only. <br />5. % Federal Share: If applicable this should be the percentage listed in Agreement Federal Share will be listed on Table I if applicable. <br />6. Federal Share: If applicable, Local Sponsor will multiply Eligible Cost by Federal Share Percentage. <br />7. Non -Federal Share: Eligible Cost (4) minus Federal Share of Invoiced Amount (6). <br />8. Percentage of State Share: This should be the State Share Percentage listed in Agreement <br />9. State Share: Multiply Non -Federal Share by State Share Percentage. <br />10. Local Share: Subtract State Share from Non -Federal Share. <br />11. Retainage Payment Requires separate line for each completed Task, Sub -Task and or Deliverable that retainage is being requested. <br />12. Withheld Retainage: Multiply State Share by 10% <br />13 State Payment: Subtract Retainage from State Share. <br />14. Total Due to Local Sponsor: Add Retainage Payment Total to State Payment Total. <br />Notes: For questions or concerns regarding this form please contact: Janice Simmons - (850)245-8222 or email at Janice.L.Simmons@dep.state.fl.us <br />DEP Agreement No. 14183, Attachment C, Page 2 of 4 <br />