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DEP Agreement Number: <br />Name of Project: <br />Billing Number: <br />Billing Period (1): <br />FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REQUEST FOR PAYMENT <br />PART 2 — REIMBURSEMENT DETAIL <br />Individual Completing Form (2): <br />Phone Number (2): <br />REIMBURSEMENT DETAIL <br />Task SOW Invoice Eligible <br />Item Vendor Invoice Invoice Check <br />Number Number Amount Amount <br /># Name Number Date Number <br />(3) (3) (4) (5) <br />Fed <br />Share <br />(6) <br />Federal <br />Share of <br />Eligible <br />Amount <br />Non- <br />Federal <br />Share <br />(8) <br />% <br />State <br />Share <br />(g) <br />State <br />Share <br />(10) <br />Local <br />Share <br />(11) <br />Requested <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 />1 <br />0.00 1 <br />0.00 <br />- <br />Totals <br />- <br />- <br />- <br />- <br />- <br />- <br />Total Due to Local Sponsor (I <br />Form Instructions: <br />1. Billing Period: Period when services were conducted (beginning date: earliest date of services conducted; end date: latest date of services conducted). <br />2. Person responsible for completing this form: Name and phone number if contact is needed. <br />3. Task #/SOW #: Insert a Task #/SOW # for each invoice. If invoice covers multiple Task#/SOW#, 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 Share: 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 10%. <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 the BMFA Fiscal Administrator, Beaches Fundin&&FloridaDEP.gov <br />DEP Agreement No. 23IR2, Exhibit C, Page 2 of 6 <br />