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INSTRUCTIONS FOR COMPLETING PAYMENT REQUEST SUMMARY FORM DEP AGREEMENT NO.: This is the number on your grant agreement. AGREEMENT EFFECTIVE DATES: Enter agreement execution date through end date. GRANTEE: Enter the name of the grantee's agency. GRANTEE'S GRANT MANAGER: This should be the person identified as grant manager in the grant Agreement. MAILING ADDRESS: Enter the address that you want the state warrant sent. PAYMENT REQUEST NO.: This is the number of your payment request, not the quarter number. DATE OF PAYMENT REQUEST: This is the date you are submitting the request. TOTAL AMOUNT OF THIS REQUEST: This should match the amount on the "TOTAL AMOUNT" line for the "GRANT AMOUNT 75%" column in the CURRENT REQUEST table. PERFORMANCE PERIOD: This is the beginning and ending date of the invoice period for the task/deliverable that the request is for (this must be within the timeline shown for the task/deliverable in the Agreement). PAST PAYMENTS SECTION: TASK No.: This is the number of the task/deliverable that you requested payment for. TASK PERFORMED: Select the name of the task. CATEGORY: Select the name of the authorized budget category. "GRANT AMOUNT (75%)" COLUMN: Enter the currently approved budget in the Grant Work Plan. "CUMULATIVE PAYMENT REQUESTED (75%)" COLUMN: Enter the cumulative amounts that have been requested to date for reimbursement by budget category. The total amount will auto -populate. "REMAINING BALANCE" COLUMN: The remaining balance will auto -populate. CURRENT REQUEST SECTION: TASK No.: This is the number of the task/deliverable that you are requesting payment for and/or claiming match for (must agree with the current Grant Work Plan). TASK PERFORMED: Select the name of the task. CATEGORY: Select the name of the authorized budget category. "TOTAL REQUEST (100%)" COLUMN: Enter the amount that was expended for this task during the period for which you are requesting reimbursement for this task. This must agree with the currently approved budget in the current Grant Work Plan of your grant Agreement. Do not claim expenses in a budget category that does not have an approved budget. Do not claim items that are not specifically identified in the current Grant Work Plan. Enter the 1001/o amount of each task for which you are requesting reimbursement and the form will calculate 75% and 25% in the GRANT AMOUNT and GRANTEE MATCH columns. The column total will auto -populate on the "TOTAL AMOUNT' line. GRANTEE'S CERTIFICATION: Check all boxes that apply. Identify any licensed professional service providers that certified work or services completed during the period included in the request for payment. Must be signed by both the Grantee's Grant Manager as identified in the grant agreement and the Grantee's Fiscal Agent. NOTES: If claiming reimbursement for travel, you must include copies of receipts and a copy of the travel reimbursement form approved by the Department of Financial Services, Chief Financial Officer. Documentation for match claims must meet the same requirements as those expenditures for reimbursement. Exhibit C, DEP Agreement #: CV003 4 of 4 Rev. 9/25/2025