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Attachment C <br /> JUSTIFICATION OF ADVANCE PAYMENT <br /> RECIPIENT: <br /> Indicate by checking one of the boxes bthe elow, if you are requesting an advance. If an advance payment <br /> u der this Agreedment et data on <br /> to s. 216.181(16),t is Fla.Stat uThe at be mounttwhi which be advanced shall <br /> not exceed the expected cash needs of the reciprenwi m the initial three months. <br /> [ ] NO ADVANCE REQUESTED I I ADVANCE REQUESTED <br /> Advance payment of $ is requested . Balance of <br /> No advance payment is requested. payments will be made on a reimbursement basis. These funds <br /> Payment wilt be solely on a are needed to pay staff, award benefits to clients, duplicate forms <br /> reimbursement basis. No additional and purchase start-up supplies and equipment. We would not be <br /> information is required . able to operate the program without this advance. <br /> ADVANCE REQUEST WORKSHEET <br /> If you are requesting an advance, complete the following worksheet <br /> (A) (13) (C) (D) <br /> FFY FFY FFY Total <br /> DESCRIPTION 2004-2005 2005-2006 2006-2007 <br /> 1 INITIAL CONTRACT ALLOCATION <br /> 2 FIRST THREE MONTHS CONTRACT <br /> EXPENDITURES' <br /> 3 AVERAGE PERCENT EXPENDED IN FIRST <br /> THREE MONTHS <br /> Divide line 2 b line 1 . <br /> First three= expenditures need only be provided for the years in which you requested an advance. If <br /> you do not have this information, call your consultant and they will assist you. <br /> MAXIMUM ADVANCE ALLOWED CALULATION: <br /> X s - <br /> Cell D3 DEM Award MAXIMUM <br /> (Do not include any match) ADVANCE <br /> REQUEST FOR WAIVER OF CALCULATED MAXIMUM <br /> [ ] Recipient has no previous DCA/DEM contract history. Complete Estimated Expenses chart and <br /> Explanation of Circumstances below. <br /> [ ] Recipient has exceptional circumstances that require an advance greater than the Maximum <br /> Advance calculated above. <br /> 34 <br />