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ATTACHMENT D- I <br /> FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br /> BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br /> REQUEST FOR PAYMENT — PART I <br /> PAYMENT SUMMARY <br /> Name of Project : AMBERSAND BEACH NOURISHMENT <br /> Grantee : INDIAN RIVER COUNTY DEP Contract Number: 07IR3 <br /> Billing Number : Billing Period : <br /> Billing Type : ❑ Interim Billing ❑ Final Billing <br /> Costs Incurred This Payment Request : <br /> Federal Share * State Share Local Share Total <br /> * if applicable <br /> Cost Summary : <br /> State Funds Obligated $ Local Funds Obligated $ <br /> Less Advance Pay $ Less Advance Pay $ <br /> Less Previous Payment $ Less Previous Credits $ <br /> Less Previous Retained $ <br /> Less This Payment $ Less This Credit $ <br /> Less This Retainage ( 10%) $ Local Funds Remaining $ <br /> State Funds Remaining $ <br /> Certification : I certify that this billing is correct and is based upon actual obligations of record by the <br />grantee ; that <br /> payment from the State Government has not been received; that the work and/or services are in accordance with <br /> the <br /> Department of Environmental Protection, Bureau of Beaches and Coastal Systems approved Project Agreement including <br /> any amendments thereto ; and that progress of the work and/or services are satisfactory and are consistent with the amount <br /> billed. <br /> Name of Project Administrator Signature of Project Administrator Date <br /> Name of Project Financial Officer Signature of Project Financial Officer Date <br /> DEP Agreement No . 071R3 , Amendment No. 1 , Attachment D- 1 , Page I of 3 <br />