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DEP Agreement No. Payment Request No. Project Title: Grantee's Grant Manager Name: Grantee Name & Mailing Address for Payment: Task No.: EXHIBIT C PART 1 - PAYMENT REQUEST FORM CZ219 Request Date: Jones' Pier Wetland and Hammock Restoration Project Beth Powell 5500 77th Street Vero Beach, FL 32967 Performance Period - Date Range: (Start date - End date) Total Amount(s) Requested: GRANT EXPENDITURES SUMMARY CATEGORY OF EXPENDITURE (As authorized) AMOUNT OF THIS REQUEST Q CUMULATIVE PAYMENT REQUESTS MATCHING FUNDS FOR THIS REQUEST CUMULATIVE MATCHING FUNDS Salaries/Wages Fringe Benefits Indirect Cost Contractual (Subcontractors) Travel Equipment (Direct Purchases) Rental/Lease of Equipment Miscellaneous/Other Expenses Land Acquisition TOTAL AMOUNT $ - $ - $ - $ - TOTAL TASK/DELIVERABLE BUDGET AMOUNT Less Total Cumulative Payment Request of: $ - $ TOTAL REMAINING IN TASK $$ - GRANTEE CERTIFICATION 1. The disbursement amount requested is for allowable costs for the project described in Attachment 3 of the Agreement. 2. All costs included in the amount requested have been satisfactorily performed, received, and applied toward completing the project; such costs are documented by invoices or other appropriate documentation as required in the Agreement. 3. The Grantee has paid such costs under the terms and provisions of contracts relating directly to the project; and the Grantee is not in default of any terms or provisions of the contracts. Grantee's Grant Manager's Signature Grantee's Fiscal Agent Signature Print Name Print Name Telephone Number Telephone Number DO NOT ATTEMPT TO MODIFY THIS FORM Note: Shaded areas auto calculate. Exhibit C - Part 1