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STATE OF FLORIDA <br />WDIAN RIVER COUNTY <br />THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT <br />s <br />Depart COPY OF THE ORnINAL ON FILE IN THIS OFFICE.- <br />RYAN L. BUTLER, CLERK l <br />oraFlorida Department of Environmenlim r c <br />DATE <br />m EXHIBIT C <br />o <br />PAYMENT REQUEST SUMMARY FORM <br />^'went al Pto <br />Required Signatures: Adobe Signature <br />Date: <br />Grantee <br />Billing Period: <br />DEP Division: <br />Project Name and Number <br />Billing #: <br />DEP Program: <br />CERTIFICATION: I hereby certify that the above expenses were incurred for the work being <br />accomplished in the attached progress reports. <br />Project Administrator <br />Date <br />CERTIFICATION: I hereby certify that the documentation has been maintained as required to support the <br />project expenses as reported above and is available for audit upon request. <br />Project Financial Officer <br />Date <br />DRP -115 (Effective 06-19-2015) Page I of I <br />Project Costs This Billing <br />Cumulative Project Costs <br />Contractual Services <br />DRP -116 <br />Grantee Labor <br />DRP -117 <br />Employee Benefits <br />of Salaries) <br />Direct Purchases: Materials & Supplies <br />DRP -118 <br />Grantee Stock <br />DRP -120 <br />Equipment <br />DRP -119 <br />Land Value <br />Indirect Costs <br />(15% of Grantee Labor) <br />TOTAL PROJECT COSTS <br />$ 0.00 J$0.00 <br />CERTIFICATION: I hereby certify that the above expenses were incurred for the work being <br />accomplished in the attached progress reports. <br />Project Administrator <br />Date <br />CERTIFICATION: I hereby certify that the documentation has been maintained as required to support the <br />project expenses as reported above and is available for audit upon request. <br />Project Financial Officer <br />Date <br />DRP -115 (Effective 06-19-2015) Page I of I <br />