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Grantee's Certification of Payment Request <br />I, , on behalf of <br />(Print name of Grantee's Grant Manager designated in the Agreement) <br />(Print name of Grantee) <br />DEP Agreement No. <br />and Payment Request No. <br />, do hereby certify for <br />that: <br />1. The disbursement amount requested is for allowable costs for the project described in Attachment 3 of the Agreement. <br />2. All costs included in the amount requested have been satisfactorily purchased, performed, received, and applied toward <br />completing the project; such costs are documented by invoices or other appropriate documentation as required in the Agreement. <br />The Grantee has paid such costs under the terms and provisions of contracts relating directly to the project; and the Grantee is not in <br />default of any terms or provisions of the contracts. <br />Grantee's Grant Manager's Signature <br />Print Name <br />Grantee's Fiscal Agent Signature <br />Print Name <br />Telephone Number Telephone Number <br />Attachment B-1, DEP Agreement No. 50839, Page 2 of 6 <br />