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FLORIDA DEPARTMENT OF IENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REQUEST FOR PAYMENT — PART II <br />Name of Project: Billing Period (1): <br />Billing Number: Person Completing Form & Telephone Number (2): <br />DEP Agreement Number: <br />REIMBURSEMENT DETAIL <br />Task/Deliverable <br />NOMMM <br />1(13) <br />Withheld <br />State <br />im <br />Total Due to Local Sponsor <br />Form Instructions: <br />1. Billing Period: Should reflect Invoice services performed date. (beginning date -earliest date of services, end <br />2. Person responsible for completing this form: Please identify the person responsible for completing information <br />3. Deliverable k: Must identify completed deliverable(s) for each invoice. If invoice covers multiple deliverable <br />4. Invoice Amount <br />5. Eligible Cost: Invoice amount paid by Local Sponsor less ineligible cost for Line Item Deliverable only. <br />6. % Federal Share: If applicable this should be the percentage listed in Agreement. Federal Share will be lister <br />7. Federal Share: If applicable, Local Sponsor will multiply Eligible Cost by Federal Share Percentage. <br />8. Non -Federal Share: Eligible Cost (5) minus Federal Share of Invoiced Amount (7). <br />9. Percentage of State Share: This should be the State Share Percentage listed in Agreement. <br />l0. State Share: Multiply Non -Federal Share by State Share Percentage. <br />11. Local Share: Subtract State Share from Non -Federal Share. <br />12. Retainage Payment: Requires separate line for each completed Task, Sub -Task and or Deliverable that rel <br />13. Withheld Retainage: Multiply State Share by 10%. <br />14. State Payment: Subtract Retainage from State Share. <br />15. Total Due to Local Sponsor: Add Retainage Payment Total (12) to State Payment Total (14). <br />Please redact all sensitive financial information from the invoices and other supporting documentation to I <br />Notes: For questions or concerns regarding this form please contact: Janice Simmons - (850)245-2978 or email <br />DEP Agreement No. 171R1, Exhibit D, Page 2 of 5 <br />late - latest date of services performed). <br />if clarification is needed. <br />, that invoice would be listed multiple times, a line item for each deliverable. <br />on Table I if applicable. <br />is being requested. <br />submitted with this Payment Request Form. <br />Janice.L.Simmons@dep.state.fl.us <br />