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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REQUEST FOR PAYMENT <br />PART II —REIMBURSEMENT DETAIL <br />DEP Agreement Number: <br />Name of Project: Individual Completing Form (2): <br />Billing Number: Phone Number (2): <br />Billing Period (1): _ <br />REIMBURSEMENT DETAIL <br />sow 1I nvoice <br />Invoice 7Ch emc k Task N Number Number Amount <br />Federal <br />Share of I <br />Eligible <br />Non- <br />Federal <br />Share <br />t <br />Requested <br />Retainage <br />Payment <br />■_--_—___.��. <br />1 1 tt <br />m <br />t t t <br />t t t <br />Total Due to Local Sponsor (1 <br />Form Instructions: <br />I . Billing Period: Period when services were conducted (beginning date: earliest date of services conducted; end date: latest date ofscrvices conducted). <br />2. Person responsible for completing this form: Name and phone number ifcontact is needed. <br />3. Task AJSOW 11: Insert a Task 41SOW N for each invoice. If invoice covers multiple Taskg/SOWH, then that invoice should be listed multiple times, a line item for each deliverable. <br />4. Invoice amount: Full amount of invoice. <br />5. Eligible Amount: Invoice amount paid by Local Sponsor less ineligible cost for line item deliverable only. <br />6. % Federal Share: If applicable, the federal cost share percentage listed in Agreement. <br />7. Federal Share of Eligible Amount: If applicable, Local Sponsor will multiply Eligible Amount (5) by % Federal Share (6). <br />8. Non -Federal Share: Eligible Amount (5) minus Federal Share of Eligible Amount (7). <br />9. % State Sharc: The state cost share percentage listed in Agreement. <br />10. State Share: Multiply Non -Federal Share (8) by % State Share (9). <br />11. Local Share: Subtract State Share (10) from Non -Federal Share (8). <br />12. Requested 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 (10) by 101/6. <br />14. State Payment: Subtract Withheld Retainage (13) from State Share (10). <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 />**For questions or concerns regarding this form please contact: Janice Simmons, Fiscal Administrator, 850-245-7620, Janice,L.SimmonsG+?FloridaDEP.t ov <br />DEP Agreement No. 221R1, Exhibit C, Page 2 of 5 <br />