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ATTACHMENT D <br />FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br />REQUEST FOR PAYMENT — PART I <br />14: u ► uu:: <br />Name of Project: AMBERSAND BEACH NOURISHMENT <br />Grantee: INDIAN RIVER COUNTY DEP Contract Number: 071 R3 <br />Billing Number: <br />Costs Incurred This Payment Request: <br />Federal Share* <br />State Share <br />*if applicable <br />Cost <br />Summary: <br />State <br />Funds Obligated <br />$ <br />Less <br />Advance Pay <br />$ <br />Less <br />Previous Payment <br />$ <br />Less <br />Previous Retained <br />$ <br />Less <br />This Payment <br />$ <br />Less <br />This Retainage (1O%) <br />$ <br />State <br />Funds Remaining <br />$ <br />Billing Period: <br />Billing Type: ❑ Interim Billing ❑ Final Billing <br />Local Share Total <br />Local Funds Obligated <br />Less Advance Pay <br />Less Previous Credits <br />Less This Credit <br />Local Funds Remaining <br />Certification: I certify that this billing is correct and is based upon actual obligations of record by the grantee; that <br />payment from the State Government has not been received; that the work and/or services are in accordance with 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 <br />Signature of Project Administrator Date <br />Name of Project Financial Officer Signature of Project Financial Officer Date <br />DEP Agreement No. 07IR3, Attachment D, Page I of 3 <br />