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INSTRUCTIONS FOR COMPLETING <br /> PAYMENT REQUEST SUMMARY FORM <br /> PAYMENT REQUEST NO.: This is the number of your payment request,not the quarter number. <br /> DEP AGREEMENT NO.: This is the number on your grant agreement. <br /> DATE: This is the date that you are submitting the payment request. <br /> PERFORMANCE PERIOD: This is the beginning and ending date of the performance period for the Task/Deliverable that the <br /> request is for(this must be within the timeline shown for the Task/Deliverable in the Agreement). <br /> TASK/DELIVERABLE NO.: Identify the number of the Task/Deliverable that you are requesting payment for and/or claiming <br /> match for (must agree with the current Grant Work Plan). Note: If payment request includes more than one Task/Deliverable, <br /> additional pages should identify each Task/Deliverable Number,its corresponding budget amount,and the amount requested. <br /> TASK BUDGET AMOUNT: List the Task budget amount as identified in the Grant Work Plan for the corresponding <br /> Task/Delverable. Note: If payment request includes more than one Task/Deliverable, additional pages should identify each <br /> Task/Deliverable Number,its corresponding budget amount,and the amount requested. <br /> GRANTEE: Enter the name of the Grantee's agency and the address to which you want the state warrant sent. <br /> GRANTEE CONTACT: List the name and telephone number for the Grantee's grant manager or other point of contact regarding the <br /> payment request submittal. <br /> GRANT EXPENDITURES SUMMARY SECTION: <br /> "AMOUNT OF THIS REQUEST" COLUMN: Enter by authorized category of expenditure the amount for which you are <br /> requesting reimbursement for this task. This must agree with the currently approved budget in the current Grant Work Plan of your <br /> grant Agreement. Do not claim expenses in a budget category that does not have an approved budget. Do not claim items that are not <br /> specifically identified in the current Grant Work Plan. Enter the column total on the"TOTAL AMOUNT" line. Enter the amount of <br /> all Tasks on the"TOTAL BUDGET(ALL TASKS)"line. Enter the total cumulative amount of this request and all previous payments <br /> on the "LESS TOTAL CUMULATIVE PAYMENT REQUESTS OF" line. Deduct the "LESS TOTAL CUMULATIVE PAYMENT <br /> REQUESTS OF" from the"TOTAL BUDGET(ALL TASKS)"for the amount to enter on the "TOTAL REMAINING(ALL TASKS)" <br /> line. <br /> "TOTAL CUMULATIVE PAYMENT REQUESTS"COLUMN: Enter the cumulative amounts that have been requested to date <br /> for reimbursement by budget category. The final request should show the total of all requests; first through the final request (this <br /> amount cannot exceed the approved budget amount for that budget category for the Task(s)you are reporting on). Enter the column <br /> total on the"TOTAL PAYMENT REQUEST"line. Do not enter anything in the shaded areas. <br /> "MATCHING FUNDS"COLUMN: Enter the amount to be claimed as match for the performance period for the Task(s)you are <br /> reporting on. This needs to be shown under specific budget categories according to the currently approved Grant Work Plan. Enter <br /> the total on the"TOTAL AMOUNT"line for this column. Enter the match budget amount on the"TOTAL BUDGET(ALL TASKS)" <br /> line for this column. Enter the total cumulative amount of this and any previous match claimed on the"LESS TOTAL CUMULATIVE <br /> PAYMENTS OF" line for this column. Deduct the"LESS TOTAL CUMULATIVE PAYMENTS OF" from thc"TOTAL BUDGET <br /> (ALL TASKS)"for the amount to enter on the"TOTAL REMAINING(ALL TASKS)"line. <br /> "TOTAL CUMULATIVE MATCHING FUNDS"COLUMN: Enter the cumulative amounts you have claimed to date for match <br /> by budget category. Put the total of all on the line titled"TOTAL PAYMENT REQUEST." The final request should show the total of <br /> all claims,first claim through the final claim,etc. Do not enter anything in the shaded areas. <br /> GRANTEE'S CERTIFICATION: Check all boxes that apply. Identify any licensed professional service providers that certified <br /> work or services completed during the period included in the request for payment.Must be signed by both the Grantee's Grant <br /> Manager as identified in the grant agreement and the Grantee's Fiscal Agent. <br /> Documentation for match claims must meet the same requirements as those expenditures for reimbursement. <br /> DEP Agreement No.NS027,Exhibit D,Page 3 of 5 <br />