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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 />Request Request <br />Reci lent: Indian River Project Name: PS Project Number: Date: <br />Budget Categories <br />Unit Price ($) <br />Quantity <br />Total Amount <br />Previous <br />Current Request <br />Deliverable Items <br />($) <br />Request <br />Amount ($) <br />Amount $ <br />A. Systems (Hardware, Software, <br />Equipment & Labor) <br />B. Services (i.e. Training, Maintenance <br />and Warranty Items) <br />Request for Payment to Rural Community or Rural Area of <br />Oonortunitv Total <br />Approximate amount of funding available (Percentage) % <br />Documentation Received bv. <br />Signature of Authorized Official <br />Date <br />DMS -P1-25-07-17 Page 1 of 2 <br />rn -4 <br />Z�c <br />r - TM <br />C> <br />m0� <br />�Z <br />0 <br />0Z <br />r� <br />M <br />MN <br />A-4 <br />D <br />0 <br />M <br />