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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br /> BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br /> REQUEST FOR PAYMENT — PART II <br /> REIMBURSEMENT DETAIL <br /> Name of Project: Billing# Billing Period : DEP CONTRACT NUMBER Invoice Adjustments (To be completed by DEP: <br /> Grantee : Reasons for changes noted below) <br /> per per es <br /> Eligible Total Amount Chan BBCS Changes BBCS App <br /> roved <br /> Item # Date OF Invoice # Amount Paid Project sowiBiD # (s) Vendor Name Check or Debit# Eligible for State g P <br /> 9 P <br /> INVOICE Vendor (1 ) Share (4) Projeet Manager (6,6) Accountant (6,6) Eligible Cost (6) <br /> Item (2) <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> Totals for all items on <br /> Item # Notes and invoice adjustment explanations per item # (6) <br /> Certification : I certify that the purchases noted above were used in accomplishing the project; and that invoices, check vouchers, copies of checks, and <br /> other purchasing documentation are maintained as required to <br /> support the cost reported above and are available for audit upon request. <br /> Name/Signature of Project Administrator Date <br /> Name/Signature of Project Financia) Officer Date <br /> Form Instructions: <br /> ( 1 ) Grantee: enter exact amount of check or debit. <br /> (2) Grantee: enter the subtask ID# from the Eligible Project Item table of the DEP Grant. <br /> (3) Scopes of work and bids that have been approved for DEP cost share may be assigned a tracking identifier number. Grantee: Insert this tracking <br /> number when applicable. <br /> (4) Grantee: insert only the amount of vender payment that is assumed to be eligible for DEP cost share. <br /> (S) Grantee : DEP Project Managers and accountants will make necessary corrections or adjustments within the terms of the contract and in accordance <br />with state rule. <br /> 6 DEP staff: Enter the total amount of line item increase or decrease: if the adjustment is a decrease, preceed the amount with the "" minus <br /> sign . <br /> DEP Agreement No . 07IR3 , Amendment No . 1 , Attachment D- 1 , Page 2 of 3 <br />