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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REQUEST FOR PAYMENT <br />PART IV—CERITIFICATION OF DISBURSEMENT REQUEST <br />Name of Project: Wabasso Beach Restoration Proiect — Sector 3 <br />Local Sponsor: Indian River County <br />DEP Agreement Number: 221RI <br />Billing Number: <br />Certification: l certify that this billing is correct and is based upon actual obligations of record by the Local <br />Sponsor; that payment from the State Government has not been received; that the work and/or services are <br />in accordance with the Department of Environmental Protection, Beach Management Funding Assistance <br />Program's approved Project Agreement including any amendments thereto; and that progress of the work <br />and/or services are satisfactory and are consistent with the amount billed. The disbursement amount <br />requested on Page 1 of this form is for allowable costs for the project described in the Attachment 3, Grant <br />Work Plan. <br />I certify that the purchases noted were used in accomplishing the project; and that invoices, check vouchers, <br />copies of checks, and other purchasing documentation are maintained as required to support the cost <br />reported above and are available for audit upon request. <br />Name of Project Administrator <br />Name of Project Financial Officer <br />Signature of Project Administrator <br />Signature of Project Financial Officer <br />DEP Agreement No. 221R1, Exhibit C, Page 4 of 5 <br />Date <br />Date <br />