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ATTACHMENT B <br />PAYMENT REQUEST SUMMARY FORM <br />GRANTEE: <br />DEP AGREEMENT NO.: G0182 <br />DATE OF REQUEST: <br />GRANTEE'S GRANT MANAGER: <br />PAYMENT REQUEST NO.: <br />PERFORMANCE <br />PERIOD: <br />AMOUNT PERCENT MATCHING <br />REQUESTED:$ REQUIRED: <br />GRANT EXPENDITURES SUMMARY SECTION <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 <br />55-223 (02/04) <br />DEP <br />Agreement No. <br />G0182, <br />Attachment B, <br />Page 1 of 2 <br />s, <br />PPPPP <br />©©© <br />• • <br />#© <br />� <br />� s <br />, two . � , <br />-r—^-�r <br />;—�• <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 <br />55-223 (02/04) <br />DEP <br />Agreement No. <br />G0182, <br />Attachment B, <br />Page 1 of 2 <br />