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Attachment I <br />Request for Payment to Rural Community or Rural Area of Opportunity <br />(Rural Payment) <br />Prepare an itemized Request for Payment to Rural Community or Rural Area of Opportunity in each budget category for each deliverable. <br />Attach copies of purchase orders, itemized invoices, and any other expenditure justifications which reflect the deliverables provided <br />during the reporting period. If there is insufficient space, please include details in an attachment. <br />Budget Categories <br />PSAP <br />Quantity <br />Total <br />Previous <br />Current <br />Deliverable Items <br />Project <br />Upgrade <br />Request <br />Request <br />Request <br />Recipient: <br />Indian River <br />Name: <br />Project <br />Number: <br />Amount $ <br />Date: <br />A. Systems (Hardware, Software, <br />Budget Categories <br />Unit Price ($) <br />Quantity <br />Total <br />Previous <br />Current <br />Deliverable Items <br />Amount ($) <br />Request <br />Request <br />Amount $ <br />Amount $ <br />A. Systems (Hardware, Software, <br />Equipment & Labor) <br />B. Services (i.e. Training, <br />Maintenance and Warranty Items) <br />Request for Payment to Rural Community or Rural Area <br />of Opportunity Total <br />Approximate amount of funding available (Percentage) % <br />Documentation Received by: <br />Signature of Authorized Official <br />Date <br />DMS -P1-24-07-17 Page 1 of 2 <br />n0D <br />r- •�� rn <br />0300 <br />�Q <br />0Z <br />r r - <br />m <br />M <br />