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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REQUEST FOR PAYMENT — PART H <br />Name of Project: Billing Period (1): <br />Billing Number: Person Completing Form & Telephone Number (2): <br />DEP Agreement Number: <br />REIMBURSEMENT DETAIL <br />Item <br /># <br />Vendor <br />Name <br />Invoice <br />Number <br />Invoice <br />Date <br />Check <br />Number <br />Task <br />Number <br />(3) <br />SOW <br />Number <br />(3) <br />Invoice <br />Amount(4) <br />Eligible <br />Cost (5) <br />% <br />Fed <br />Share <br />(6) <br />Federal <br />Share of <br />Invoice <br />Amount <br />Non _ <br />Federal <br />Share <br />(8) <br />% <br />State <br />Share <br />(9) <br />State <br />Share <br />(10) <br />Local <br />Share <br />(11) <br />Retainage <br />Payment <br />(12) <br />Withheld <br />Retainage <br />(13) <br />State <br />Payment <br />(14) <br />- <br />- <br />$0.00 <br />0.00 <br />0.00 <br />0.00 <br />- <br />Totals <br />- <br />- <br />- <br />- <br />- <br />- <br />Total Due to Local Sponsor (15) <br />Form Instructions: <br />1. Billing Period: Should reflect Invoice services performed date. (beginning date - earliest date of services, end date - latest date of services performed). <br />2. Person responsible for completing this form: Please identify the person responsible for completing information if clarification is needed. <br />3. Task #: Must identify Task.. <br />4. SOW #: Must identify SOW(s) for each invoice. If invoice covers multiple SOW, that invoice would be listed multiple times, a line item for each SOW. <br />4. Invoice Amount <br />5. Eligible Cost: Invoice amount paid by Local Sponsor less ineligible cost for Line Item Deliverable only. <br />6. % Federal Share: If applicable this should be the percentage listed in Agreement. Federal Share will be listed on Table 1 if applicable. <br />7. Federal Share: If applicable, Local Sponsor will multiply Eligible Cost by Federal Share Percentage. <br />8. Non -Federal Share: Eligible Cost (5) minus Federal Share of Invoiced Amount (7). <br />9. Percentage of State Share: This should be the State Share Percentage listed in Agreement. <br />10. State Share: Multiply Non -Federal Share by State Share Percentage. <br />11. Local Share: Subtract State Share from Non -Federal Share. <br />12. Retainage Payment: Requires separate line for each completed Task, Sub -Task and or Deliverable that retainage is being requested. <br />13. Withheld Retainage: Multiply State Share by 10%. <br />14. State Payment: Subtract Retainage from State Share. <br />15. Total Due to Local Sponsor: Add Retainage Payment Total (12) to State Payment Total (14). <br />Please redact all sensitive financial information from the invoices and other supporting documentation to be submitted with this Payment Request Form. <br />Notes: For questions or concerns regarding this form please contact: Janice Simmons - (850)245-2978 or email at Janice.L.Simmons@dep.state.fl.us <br />DEP Agreement No. 19183, Exhibit C, Page 2 of 5 <br />