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EXHIBIT C PAYMENT REQUEST SUMMARY FORM DEP Agreement No. NSO45 Payment Request No. Request Grantee: (Name & Mailing Address) Grantee's Grant Manager Task No(s). Task Amount(s) Requested: 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. DEP Agreement No. NSO45 Exhibit C, Page l of 6 AMOUNT OF THIS PREVIOUS TOTAL CUMULATIVE MATCHING TOTAL REQUEST PAYMENT PAYMENT FUNDS FOR THIS CUMULATIVE CATEGORY OF EXPENDITURE REQUESTS REQUESTS REQUEST MATCHING FUNDS As authorized) Salaries/Wages $ $ $ S $ Fringe Benefits $ $ - $ $ S Indirect Cost $ $ - $ S _ S Contractual (Subcontractors) $ $ $ $ $ Travel $ $ $ S $ Equipment (Direct Purchases) S S $ $ S Rental/Lease of Equipment $ $ S S S Miscellaneous/Other Expenses $ $ $ $ $ Land Acquisition $ $ $ $ S TOTAL AMOUNT $ $ $ $ $ TOTAL BUDGET (ALL TASKS) $ S 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. DEP Agreement No. NSO45 Exhibit C, Page l of 6