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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br /> BEACH MANAGEMENT FUNDING ASSISTANCE PROGRAM <br /> REQUEST FOR PAYMIENT — PART FI <br /> REIMBURSEMENT DETAIL <br /> Name of Project; <br /> Grantee : Billing# Billing Period : DEP CONTRACT NUMBER Invoice Adjustments (To be completed by DEP ; <br /> Pilo 11 Reasons for changes noted below) <br /> Item # Data OF Amount Paid Eligible Total Amount <br /> INVOICE Invoice Vendor (l ) a) oct PrSowratorf (3) VandorNamo Chock orDablYm Eligible for state Chanoos psrSBCS Changes parBOCS <br /> Approved <br /> Item (a) Share (4) Pre}act Manager ( 6,6 ) Accountant (6,61 Eligible Cost (5) <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 ' <br /> Item ss : . Totals for all items ' on age: <br /> Notes and Invoice adjustment explanations per item N (6) <br /> Cortlficatlon ; 1 certify that the purohnsos noted above woro used In accomplishing the project; and that invoices, chock vouchers, coplas of chocks, and <br /> other purchasing documentation are maintained as required to <br /> support the cost reported above and aro available for audit upon raquost. <br /> Name/Signature orProject Administrator Date <br /> NaralJSignaturn ofProject Financial officer ntua <br /> Form Inatrucdons: <br /> (1 ) Grantee: enter exact amount or check or debit. <br /> (2) Grantee: enter the subtask IOP from the Eligible Project Item table of the OEP Grant <br /> (a ) Scopes of work and bids Thal nava been approved for DEP coal share may ba assigned a backing Identifier number. Gmnlec: Insert this lrocking <br /> (a ) Grantee: Insert only the amount or vender payment that Is assumed to be aNglble for DEP cost share, number when applicable. <br /> (5) Grantee: OEP Prajec! Managers and acceuntanta will make necessary corrections or adjustments within the terms of the conleact and in accordance with <br />alala rule. <br /> 8 DEP staff: Enter the total amount of lino Item Increase or decrease: If the ad ustmant Is a decrease. PrMCCed the amount with the "=' minus <br /> sl n. <br /> DEJ' Agreement No . 071R2, Attachment C, .Page 2 of 3 <br />