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ATTACHMENT B <br /> PAYMENT REQUEST SUMMARY FORM <br /> GRANTEE : Indian River County Board of GRANTEE ' S GRANT MANAGER: <br /> County Commissioners <br /> PAYMENT REQUEST NO. : <br /> DEP AGREEMENT NO. . G0061 <br /> DATE OF REQUEST : PERFORMANCE <br /> PERIOD . <br /> AMOUNT PERCENT MATCHING <br /> REQUESTED : $ REQUIRED : <br /> GRANT EXPENDITURES SUMMARY SECTION <br /> Effective Date of Grant throu End-of-Grant Period <br /> AMOUNT OF TOTAL MATCHING TOTAL <br /> CATEGORY OF EXPENDITURE THIS REQUEST CUMULATIVE FUNDS CUMULATIVE <br /> PAYMENTS MATCHING <br /> FUNDS <br /> Salaries $ $ $ $ <br /> Fringe Benefits $ $ $ $ <br /> Travel (if authorized) $ $ $ $ <br /> Subcontracting: <br /> Planning $ $ $ $ <br /> Design $ $ $ $ <br /> Construction $ $ $ $ <br /> Construction Related Costs $ $ $ $ <br /> Equipment Purchases $ $ $ $ <br /> Supplies/Other Expenses $ $ $ $ <br /> Land N/A N/A $ $ <br /> Overhead $ $ $ $ <br /> TOTAL REQUESTED $ $ $ $ <br /> TOTAL GRANT AGREEMENT <br /> Less Total Cumulative Payments of: <br /> TOTAL REMAINING IN GRANT <br /> GRANTEE CERTIFICATION <br /> The undersigned certifies that the amount being requested for reimbursement above <br /> was for items that were charged to and utilized only for the above cited grant activities. <br /> Grantee's Grant Manager ' s Signature Grantee's Fiscal Agent <br /> Print Name Print Name <br /> Telephone Number Telephone Number <br /> DEP Agreement No. G0061 , Attachment B, Page I of 1 <br />