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EXHIBIT C <br />PAYMENT REQUEST SUMMARY FORM <br />DEP Agreement No. NSO45 Payment Request No. Request <br />Grantee: <br />(Name & Mailing Address) <br />Grantee's Grant Manager <br />Task No(s). <br />Task Amount(s) Requested: <br />GRANT EXPENDITURES SUMMARY SECTION <br />GRANTEE CERTIFICATION <br />Complete Grantee's Certification of Payment Request on Page 2 to certify that the amount being requested for reimbursement above was for items that <br />were charged to and utilized only for the above cited grant activities. <br />DEP Agreement No. NSO45 Exhibit C, Page l of 6 <br />AMOUNT OF THIS <br />PREVIOUS <br />TOTAL <br />CUMULATIVE <br />MATCHING <br />TOTAL <br />REQUEST <br />PAYMENT <br />PAYMENT <br />FUNDS FOR THIS <br />CUMULATIVE <br />CATEGORY OF EXPENDITURE <br />REQUESTS <br />REQUESTS <br />REQUEST <br />MATCHING FUNDS <br />As authorized) <br />Salaries/Wages <br />$ <br />$ <br />$ <br />S <br />$ <br />Fringe Benefits <br />$ <br />$ - <br />$ <br />$ <br />S <br />Indirect Cost <br />$ <br />$ - <br />$ <br />S _ <br />S <br />Contractual (Subcontractors) <br />$ <br />$ <br />$ <br />$ <br />$ <br />Travel <br />$ <br />$ <br />$ <br />S <br />$ <br />Equipment (Direct Purchases) <br />S <br />S <br />$ <br />$ <br />S <br />Rental/Lease of Equipment <br />$ <br />$ <br />S <br />S <br />S <br />Miscellaneous/Other Expenses <br />$ <br />$ <br />$ <br />$ <br />$ <br />Land Acquisition <br />$ <br />$ <br />$ <br />$ <br />S <br />TOTAL AMOUNT <br />$ <br />$ <br />$ <br />$ <br />$ <br />TOTAL BUDGET <br />(ALL TASKS) <br />$ <br />S <br />LESS TOTAL CUMULATIVE PAYMENT <br />REQUESTS OF: <br />$ <br />$ <br />TOTAL REMAINING <br />$ <br />(ALL TASKS) <br />$ <br />GRANTEE CERTIFICATION <br />Complete Grantee's Certification of Payment Request on Page 2 to certify that the amount being requested for reimbursement above was for items that <br />were charged to and utilized only for the above cited grant activities. <br />DEP Agreement No. NSO45 Exhibit C, Page l of 6 <br />