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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM REQUEST FOR PAYMENT - PART II REIMBURSEMENT DETAIL Name of Project: Billing# Billing Period: DEP CONTRACT NUMBER Invoice Adjustments (To be completed by DEP: Grantee: Reasons for changes noted below) Eligible Total Amount g p g p Approved Item # NV OF Invoice # Amount Paid Project sowIBID x lsl Vendor Name Check or Debit# Eligible for State Chang" per BB6, Changes per BBC5 INVOICE Vendor (1 ) Item (2) Share (4) Project Manager (6,6) Accountant (6,6) Eligible Cost (6) 1 2 3 4 5 6 7 6 9 10 Totals for all items on e: Item # Notes and invoice adjustment explanations per item # (6) Certification: 1 certify that the purchases noted above were used in accomplishing the project; and that invoices, check vouchers, copies of checks, and ether purchasing documentation are maintained as required to support the cost reported above and are available for audit upon request. Name/Sijmature of Project Administrator Dale Name/Signature of Project Financial Officer Date Form Instructions: (1 ) Grantee: enter exact amount of check or debit. (2) Grantee: enter the subtask ID# from the Eligible Project Item table of the DEP Grant. (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 number when applicable. (4) Gntee: insert only the amount of vender payment that is assumed to be eligible for DEP cost share. (5) ra Grantee: DEP Project Managers and accountants will make necessary corrections or adjustments within the terms of the contract and in accordance with state rule. 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 sign. DEP Agreement No. 071113 , Attachment D, Page 2 of 3