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Exhibit C <br />Payment Request Summary Form <br />DEP Agreement No.: CV003 <br />Agreement Effective Dates: <br />Grantee: <br />Grantee's Grant Manager: <br />Mailing Address: <br />Payment Request No.: <br />Date of Payment Request: <br />Total Amount of this Request: <br />Performance Period: I- <br />Past Payments: <br />Task Task Performed <br />No. <br />Category <br />Agreement <br />Grant Amount <br />(75%) <br />Cumulative <br />Payment <br />Requested <br />(75%) <br />Remaining <br />Balance <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />Total Amount: <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />Grant Expenditures Summary Section: <br />Task Task Performed <br />No. <br />Category <br />Total Request <br />(100%) <br />Grant Amount <br />(75%) <br />Grantee Match <br />(25%) <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />-Select- <br />-Select- <br />$ 0.00 <br />$ 0.00 <br />Total Amount: <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />Exhibit C, DEP Agreement #: <br />I of 4 <br />Rev. 9/25/2025 <br />