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EXHIBIT C PAYMENT REQUEST SUMMARY FORM DEP Agreement No. Payment Request No. Request Date: Grantee: (Name & Mailing Address) Grantee's Grant Manager Task No(s). Task Amount(s) Requested: $ GRANT EXPENDITURES SUNIMARY 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. ABO 10, Exhibit C, Page 1 of 6 155-21 PREVIOUS TOTAL MATCHING TOTAL AMOUNT OF THIS PAYMENT CUMULATIVE FUNDS FOR THIS CUMULATIVE CATEGORY OF EXPENDITURE REQUEST REQUESTS PAYMENT REQUEST MATCHING FUNDS REQUESTS As authorized Salaries/Wages $ - $ - $ - $ - $ - Fringe Benefits $ - $ $ - $ - $ Indirect Cost $ $ - $ - $ $ - Contractual (Subcontractors) $ - $ $ - $ $ Travel $ - $ $ $ - $ Equipment (Direct Purchases) $ - $ - $ - $ - $ - Rental/Lease of Equipment $ - $ $ $ $ Miscellaneous/Other Expenses $ - $ $ - $ $ Land Acquisition $ - $ $ $ - $ TOTAL AMOUNT $ $ $ $ $ TOTAL BUDGET $ $ (ALL TASKS) 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. ABO 10, Exhibit C, Page 1 of 6 155-21