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DEP Agreement No. Grantee: (Name & Mailing Address) Grantee's Grant Manager Attachment B-1 PAYMENT REQUEST SUMMARY FORM Payment Request No. Request Task No(s). Task Amount(s) Requested: S. GRANT EXPENDITURES SUMMARY SECTION GRANTEE CERTIFICATION Complete Grantee's Certification of Payment Request on Page 2 to certify that the amount being requested for reimbursement above was for items that were charged to and utilized only for the above cited grant activities. Attachment B-1, DEP Agreement No. 50839, Page 1 of6 TOTAL PREVIOUS MATCHING TOTAL AMOUNT OF THIS CUMULATIVE AUTHORIZED TASKS PAYMENT FUNDS FOR THIS CUMULATIVE REQUEST PAYMENT REQUESTS REQUEST MATCHING FUNDS REQUESTS Task 1: $ - $ - $ - $ - $ - Task 2: $ $ $ $ $ Task 3: $ $ $ $ $ Task 4: $ $ $ $ $ Task 5: $ $ $ S $ Task 6: $ $ $ $ $ Task 7: $ $ $ $ $ Task 8: $ $ $ $ $ Task 9: $ $ $ $ $ TOTAL AMOUNT $ $ $ $ $ TOTAL BUDGET $ $ (ALL TASKS) LESS TOTAL CUMULATIVE $ $ PAYMENT REQUESTS OF: TOTAL REMAINING $ $ (ALL TASKS) GRANTEE CERTIFICATION Complete Grantee's Certification of Payment Request on Page 2 to certify that the amount being requested for reimbursement above was for items that were charged to and utilized only for the above cited grant activities. Attachment B-1, DEP Agreement No. 50839, Page 1 of6