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INSTRUCTIONS FOR COMPLETING <br />ATTACHMENT B <br />PAYMENT REQUEST SUMMARY FORM <br />GRANTEE: Enter the name of the grantee's agency. <br />DEP AGREEMENT NO.: This is the number on your grant agreement. <br />DATE OF REQUEST: This is the date you are submitting the request. <br />AMOUNT REQUESTED: This should match the amount on the "TOTAL AMOUNT" line for the "AMOUNT OF THIS <br />REQUEST' column. <br />GRANTEE'S GRANT MANAGER: This should be the person identified as grant manager in the grant agreement. <br />PAYMENT REQUEST NO.: This is the number of your payment request, not the quarter number. <br />PERFORMANCE PERIOD: This is the beginning and ending date of the invoice period. <br />PERCENT MATCHING REQUIRED: Enter your match requirement here. <br />GRANT EXPENDITURES SUMMARY SECTION: <br />"AMOUNT OF THIS REQUEST" COLUMN: Enter the amount that was paid out during the invoice period. This must <br />be by budget category as in the currently approved budget in the current Grant Work Plan of your grant Agreement. Do not <br />claim expenses in a budget category that does not have an approved budget. Do not claim items that are not specifically <br />identified in the current Budget Narrative section of the current Grant Work Plan. Enter the column total on the "TOTALS" <br />line. Enter the budget amount on the "AGREEMENT AMOUNT' line. Enter the total cumulative amount of this request <br />and all previous payments on the "LESS TOTAL CUMULATIVE PAYMENTS OF' line. Deduct the "LESS TOTAL <br />CUMULATIVE PAYMENTS OF' from the "AGREEMENT AMOUNT' for the amount to enter on the "TOTAL <br />REMAINING IN GRANT' line. <br />"TOTAL CUMULATIVE PAYMENTS" COLUMN: Enter the cumulative amounts that have been paid to date for <br />expenses by budget category. The final report should show the total of all payments, first through the final payment, etc. <br />Enter the column total on the "TOTALS" line. Do not enter anything in the shaded areas. <br />"MATCHING FUNDS" COLUMN: Enter the amount to be claimed as match for the invoice period. This needs to be <br />shown under specific budget categories according to the currently approved Grant Work Plan. Enter the total on the <br />"TOTALS" line for this column. Enter the match budget amount on the "AGREEMENT AMOUNT' line for this column. <br />Enter the total cumulative amount of this and any previous match claimed on the "LESS TOTAL CUMULATIVE <br />PAYMENTS OF' line for this column. Deduct the "LESS TOTAL CUMULATIVE PAYMENTS OF' from the <br />"AGREEMENT AMOUNT' for the amount to enter on the "TOTAL REMAINING IN GRANT' line. <br />"TOTAL CUMULATIVE MATCHING FUNDS" COLUMN: Enter the cumulative amount you have claimed to date <br />for match by budget category. Put the total of all on the line titled "TOTALS." The final report should show the total of all <br />claims, first claim through the final claim, etc. Do not enter anything in the shaded areas. <br />GRANTEE CERTIFICATION: Must be signed by both the Grantee's Grant Manager as identified in the grant <br />agreement and the Grantee's Fiscal Agent. <br />NOTE: If claiming reimbursement for travel, you must include copies of receipts and a copy of the travel <br />reimbursement form approved by the Department of Financial Services, Chief Financial Officer. <br />DEP 55-223 (02/04) <br />DEP Agreement No. GO 182, Attachment B, Page 2 of 2 <br />