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EXHIBIT C <br />PART 1 - PAYMENT. REQUEST FORM <br />DEP Agreement No. CZ219 <br />Payment Request No. } 1 Request Date: r <br />Project Title: Jones' Pier Wetland and Hammock Restoration Project <br />Grantee's Grant Manager Name: <br />Grantee Name & Mailing Address <br />for Payment: <br />Beth Powell <br />5500 77th Street <br />Vero Beach, FL 32967 <br />Task No.: 1 j Total Amount(s) Requested: 1 <br />Performance Period - Date Range: (Start date- End date) <br />} <br />} <br />GRANT EXPENDITURES SUMMARY SECTION <br />CATEGORY OF <br />EXPENDITURE <br />(As authorized) <br />AMOUNT OF <br />THIS REQUEST <br />CUMULATIVE <br />PAYMENT <br />REQUESTS <br />MATCHING <br />FUNDS FOR <br />THIS REQUEST <br />CUMULATIVE <br />MATCHING <br />FUNDS <br />Salaries/Wages <br />Fringe Benefits <br />Indirect Cost <br />Contractual (Subcontractors) <br />Travel <br />Equipment (Direct Purchases) <br />Rental/Lease of Equipment <br />Miscellaneous/Other <br />Expenses <br />Land Acquisition <br />TOTAL AMOUNT <br />$ - <br />$ - <br />$ - <br />$ - <br />TOTAL TASK/DELIVERABLE <br />BUDGET AMOUNT <br />Less Total Cumulative Payment <br />Request of: <br />$ <br />$ <br />$ - <br />TOTAL REMAINING IN TASK <br />$ - <br />GRANTEE CERTIFICATION <br />1. The disbursement amount requested is for allowable costs for the project described in Attachment 3 of the Agreement. <br />2. All costs included in the amount requested have been satisfactorily performed, received, and applied toward completing the <br />project; such costs are documented by invoices or other appropriate documentation as required in the Agreement. <br />3. The Grantee has paid such costs under the terms and provisions of contracts relating directly to the project; and the Grantee is <br />not in default of any terms or provisions of the contracts. <br />Grantee's Grant Manager's Signature Grantee's Fiscal Agent Signature <br />Print Name <br />Print Name <br />Telephone Number Telephone Number <br />DO NOT ATTEMPT TO MODIFY THIS FORM <br />Note: Shaded areas auto calculate. <br />69 <br />Exhibit C- Part 1 <br />