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INSTRUCTIONS FOR COMPLETING PAYMENT REQUEST SUMMARY FORM DEP AGREEMENT NO.: This is the number on your grant agreement. PAYMENT REQEUST NUMBER: Number of payment request REQUEST DATE: Date reqeust is submitted GRANTEE: Enter the name of the grantee's agency. MAILING ADDRESS: Enter the address that you want the state warrant sent. GRANTEE'S GRANT MANAGER: This should be the person identified as grant manager in the grant Agreement. TASK NO.: This is the number of the task that you are requesting payment for and/or claiming match for (must agree with the current Grant Work Plan). TASK AMOUNT REQUESTED: This should match the amount on the "TOTAL TASK BUDGET AMOUNT" line for the "AMOUNT OF THIS REQUEST" column. GRANT EXPENDITURES SUMMARY SECTION: "AMOUNT OF THIS REQUEST" COLUMN: Enter by authorized category of expenditure the amount for which you are requesting reimbursement for this task. This must agree with the currently approved budget in the current Grant Work Plan of your grant Agreement. Do not claim expenses in a budget category that does not have an approved budget. Do not claim items that are not specifically identified in the current Grant Work Plan. Enter the column total on the "TOTAL AMOUNT" line. Enter the amount of all Tasks on the "TOTAL BUDGET (ALL TASKS)" line. Enter the total cumulative amount of this request and all previous payments on the "LESS TOTAL CUMULATIVE PAYMENT REQUESTS OF" line. Deduct the "LESS TOTAL CUMULATIVE PAYMENT REQUESTS OF" from the "TOTAL BUDGET (ALL TASKS)" for the amount to enter on the "TOTAL REMAINING (ALL TASKS)" line. "PREVIOUS PAYMENT REOUESTS" COLUMN: Enter the total cumulative amount that has been paid in previous requests. Do not include the current regeusted amount in this total. Do not enter anything in the shaded areas. "TOTAL CUMULATIVE PAYMENT REQUESTS" COLUMN: Enter the cumulative amounts that have been requested to date for reimbursement by budget category. The final request should show the total of all requests; first through the final request (this amount cannot exceed the approved budget amount for that budget category for the Task(s) you are reporting on). Enter the column total on the "TOTAL PAYMENT REQUEST" line. Do not enter anything in the shaded areas. "MATCHING FUNDS" COLUMN: Enter the amount to be claimed as match for the performance period for the Task(s) you are reporting on. This needs to be shown under specific budget categories according to the currently approved Grant Work Plan. Enter the total on the "TOTAL AMOUNT" line for this column. Enter the match budget amount on the "TOTAL BUDGET (ALL TASKS)" line for this column. Enter the total cumulative amount of this and any previous match claimed on the "LESS TOTAL CUMULATIVE PAYMENTS OF" line for this column. Deduct the "LESS TOTAL CUMULATIVE PAYMENTS OF" from the "TOTAL BUDGET (ALL TASKS) " for the amount to enter on the "TOTAL REMAINING (ALL TASKS) " line. "TOTAL CUMULATIVE MATCHING FUNDS" COLUMN: Enter the cumulative amounts you have claimed to date for match by budget category. Put the total of all on the line titled "TOTAL PAYMENT REQUEST." The final request should show the total of all claims, first claim through the final claim, etc. Do not enter anything in the shaded areas. GRANTEE'S CERTIFICATION: Must be signed by both the Grantee's Grant Manager as identified in the grant agreement and the Grantee's Fiscal Agent. ENGINEER'S CERTIFICATION: Must be signed by Professional Engineer when Construction is being reqeusted for reimbursement. Documentation for match claims must meet the same requirements as those expenditures for reimbursement. Attachment 13-1, DEP Agreement No. S0839, Page 4 of 6