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EXHIBIT D <br /> PAYMENT REQUEST SUMMARY FORM <br /> Payment Request No. DEP Agreement No. Date <br /> Performance Period(Start date-End date): <br /> Deliverables completed to support payment request(attach additional pages as needed): <br /> Task/Deliverable Task Budget <br /> Number(s): Amount: $ - <br /> Grantee: <br /> (Name&Mailing <br /> Address) <br /> Grantee Contact: <br /> (Name&Phone) <br /> GRANT EXPENDITURES SUMMARY SECTION <br /> TOTAL TOTAL <br /> CUMULATIVE MATCHING CUMULATIVE <br /> CATEGORY OF EXPENDITURE AMOUNT OF THIS PAYMENT FUNDS FOR THIS MATCHING <br /> !As authorized) REQUEST REQUESTS REQUEST FUNDS <br /> Salaries/Wages $ - $ s - $ <br /> Fringe Benefits $ - $ S - S - <br /> Indirect Cost $ - $ - $ - $ - <br /> Contractual(Subcontractors) $ - $ - S - $ - <br /> Travel $ - $ ` - $ - <br /> Equipment(Direct Purchases) $ - $ - $ - $ - <br /> Rental/Lease of Equipment $ - $ - S S - <br /> Miscellaneous/Other Expenses $ - $ S - $ - <br /> Land Acquisition $ - S - S - S - <br /> lb <br /> TOTAL AMOUNT $ 5 S S <br /> TOTAL BUDGET <br /> ALL TASKS) $ S <br /> Less Total Cumulative Payment $ $ <br /> Requests of: <br /> TOTAL REMAINING <br /> (ALL TASKS) $ S <br /> GRANTEE CERTIFICATION <br /> Complete Grantee's Certification of Payment Request on Page 2 to certify that the amount being requested for <br /> reimbursement above was for items that were charged to and utilized only for the above cited grant activities. <br /> DEP Agreement No.NS027,Exhibit D,Page 1 of 5 <br />