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DEP Agreement No. <br />Payment Request No. <br />EXHIBIT C <br />PAYMENT REQUEST SUMMARY FORM <br />R2114 <br />Grantee's Grant Manager Name: Andy Sobczak <br />Indian River County <br />Grantee Name &Mailing <br />Address for Payment: 1801 27th Street, Building A <br />Vero Beach, FL 32960 <br />Task No(s). <br />Performance Period - Date Range: <br />Request Date: <br />Total Task Amount(s) Requested: <br />GRANT EXPENDITURES SUMMARY SECTION <br />A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />J.R. SMITH, CLERK <br />CATEGORY OF <br />EXPENDITURE <br />BUDGETED <br />AMOUNT OF <br />PAYMENTS <br />REMAINING <br />(As authoriZetl) <br />AMOUNT <br />THIS REQUEST <br />RECEIVED <br />AMOUNT <br />Salaries/Wages <br />S _ <br />Fringe Benefits <br />S _ <br />Indirect Cost <br />S _ <br />Contractual <br />(Subcontractors) <br />S <br />Fixed Price <br />S _ <br />TOTALS <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 <br />completing the project; such costs are documented by invoices or other appropriate documentation as required in the <br />Agreement. <br />3. The Grantee has paid such costs under the terms and provisions of contracts relating directly to the project; and the <br />Grantee is not in default of any terms or provisions of the contracts. <br />Grantee's Grant Manager's Signature <br />Print Name <br />Telephone Number <br />Grantee's Fiscal Agent Signature <br />Print Name <br />Telephone Number <br />R2114 - Exhibit C Page 1 <br />