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2018-169
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Last modified
1/4/2021 11:20:46 AM
Creation date
9/19/2018 12:16:29 PM
Metadata
Fields
Template:
Official Documents
Official Document Type
Agreement
Approved Date
09/11/2018
Control Number
2018-169
Agenda Item Number
8.Y.
Entity Name
State of Florida Department of Environmental Protection
Subject
Standard Grant Agreement
Approval of FDEP Funding Agreement
Area
West Wabasso Phase II Septic to Sewer
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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 />
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