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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REQUEST FOR PAYMENT <br />PART 2 — REIMBURSEMENT DETAIL <br />DEP Agreement Number: 251RI <br />Name of Project: Indian River County Sector 3 Beach Nourishment Project (Wabasso) <br />Billing Number: <br />Billing Period (1): <br />Individual Completing Form (2): <br />Phone Number (2): <br />REIMBURSEMENT DETAIL <br />Item Vendor Invoice invoice Check/EFT Task SOW Invoice Eligible <br />Number Number Amount Amount <br /># Name Number Date Number <br />(3) (3) (4) (5) <br />%uested <br />Fed <br />Share <br />(6) <br />Federal <br />Share of 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 />Re q <br />Retainage <br />Payment <br />(12) <br />Withheld <br />Retainage <br />(13) <br />State <br />Payment <br />(14) <br />3. <br />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 />-1 <br />4. <br />$0.00 <br />0.00 <br />1 <br />0.00 <br />0.00 <br />6. <br />% Federal Share: If applicable, the federal cost share <br />pp percentage listed in Agreement. <br />7. <br />Federal Share of Eligible Amount: If applicable, Local Sponsor will multiply Eligible Amount (5) by % Federal Share (6). <br />� m <br />8. <br />Non -Federal Share: Eligible Amount (5) minus Federal Share of Eligible Amount (7). <br />W n 0 <br />9. <br />% State Share: The state cost share percentage listed in Agreement. <br />c 10 <br />0 <br />10. <br />State Share: Multiply Non -Federal Share (8) by % State Share (9).m <br />O <br />11. <br />Local Share: Subtract State Share (10) from Non -Federal Share (8). <br />Z <br />12. <br />Requested Retainage Payment: Requires separate line for each completed Task, Sub -Task and or Deliverable that retainage is being requested. <br />M <br />0 <br />13. <br />Withheld Retainage: Multiply State Share (10) by 10%. <br />0 Z <br />14. <br />State Payment: Subtract Withheld Retainage (13) from State Share (10). <br />m <br />15. <br />Total Due to Local Sponsor: Add Retainage Payment Total (12 to State Payment Total (14). <br />(A <br />Please redact all sensitive financial information from the invoices and other supporting documentation to be submitted with this Payment Request Form. <br />� <br />"*For questions or concerns regarding this form please contact the BMFA Fiscal Administrator, Beaches Fundine(d)FloridaDEP.gov <br />D <br />DEP Agreement No. 25IR1, Exhibit C, Page 2 of 6 <br />0 <br />Total Due to Local Sponsor (15) <br />Form Instructions: . <br />I . <br />Billing Period: Period when services were conducted (beginning date: earliest date of services conducted; end date: latest date of services conducted). <br />2. <br />Person responsible for completing this form: Name and phone number if contact is needed. <br />3. <br />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. <br />Invoice amount: Full amount of invoice. <br />r 0 D <br />5. <br />Eligible Amount: Invoice amount paid by Local Sponsor less ineligible cost for line item deliverable only. <br />rn { <br />6. <br />% Federal Share: If applicable, the federal cost share <br />pp percentage listed in Agreement. <br />7. <br />Federal Share of Eligible Amount: If applicable, Local Sponsor will multiply Eligible Amount (5) by % Federal Share (6). <br />� m <br />8. <br />Non -Federal Share: Eligible Amount (5) minus Federal Share of Eligible Amount (7). <br />W n 0 <br />9. <br />% State Share: The state cost share percentage listed in Agreement. <br />c 10 <br />0 <br />10. <br />State Share: Multiply Non -Federal Share (8) by % State Share (9).m <br />O <br />11. <br />Local Share: Subtract State Share (10) from Non -Federal Share (8). <br />Z <br />12. <br />Requested Retainage Payment: Requires separate line for each completed Task, Sub -Task and or Deliverable that retainage is being requested. <br />M <br />0 <br />13. <br />Withheld Retainage: Multiply State Share (10) by 10%. <br />0 Z <br />14. <br />State Payment: Subtract Withheld Retainage (13) from State Share (10). <br />m <br />15. <br />Total Due to Local Sponsor: Add Retainage Payment Total (12 to State Payment Total (14). <br />(A <br />Please redact all sensitive financial information from the invoices and other supporting documentation to be submitted with this Payment Request Form. <br />� <br />"*For questions or concerns regarding this form please contact the BMFA Fiscal Administrator, Beaches Fundine(d)FloridaDEP.gov <br />D <br />DEP Agreement No. 25IR1, Exhibit C, Page 2 of 6 <br />0 <br />