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ATTACHMENT B <br /> PAYMENT REQUEST SUMMARY FORM <br /> GRANTEE . GRANTEE ' S GRANT MANAGER: <br /> DEP AGREEMENT NO. : PAYMENT REQUEST NO . : <br /> DATE OF REQUEST : PERFORMANCE <br /> PERIOD . <br /> AMOUNT PERCENT MATCHING <br /> REQUESTED : $ REQUIRED : <br /> GRANT EXPENDITURES SUMMARY SECTION <br /> Effective Date of Grant throu yh End-of-Grant Period <br /> IN <br /> AMOUNT OF TOTAL MATCHING TOTAL <br /> CATEGORY OF EXPENDITURE THIS REQUEST CUMULATIVE FUNDS CUMULATIVE <br /> PAYMENTS MATCHING <br /> FUNDS <br /> Salaries N/A N/A $ $ <br /> Fringe Benefits N/A N/A $ $ <br /> Travel (if authorized) N/A N/A N/A N/A <br /> Subcontracting : <br /> Planning $ $ $ $ <br /> Design $ $ $ $ <br /> Construction $ $ $ $ <br /> Construction Related Costs $ $ $ $ <br /> Equipment Purchases N/A N/A N/A N/A <br /> Supplies/Other Expenses $ $ $ $ <br /> Land N/A N/A N/A N/A <br /> Indirect N/A N/A N/A N/A <br /> TOTALS $ $ $ $ <br /> AGREEMENT AMOUNT $ $ <br /> Less Total Cumulative Payments of. $ $ <br /> TOTAL REMAINING IN GRANT $ $ <br /> GRANTEE CERTIFICATION <br /> The undersigned certifies that the amount being requested for reimbursement above <br /> was for items that were charged to and utilized only for the above cited grant activities . <br /> Grantee's Grant Manager ' s Signature Grantee's Fiscal Agent <br /> Print Name Print Name <br /> Telephone Number Telephone Number <br /> DEP Agreement No . GO 143 , Attachment B, Page 1 of 2 <br />