Okaloosa County BOCC — October 21, 2014 — S0717attachment B

ATTACHMENT B PAYMENT REQUEST SUMMARY FORM Grantee: Grantee's Grant Manager: ---------------- Mailing Address=~----------- Payment Request No.: _ _ _ _ _ _ __ DEP Agreement No.: _S_0_7_1_7_ _ _ _ __ Date Of Request: Neighboring County: _ _ _ _ _ _ _ _ _ _ _ _ __ Amount Requested:$_ _ _ _ _ _ _ _ __ GRANT EXPENDITURES SUMMARY SECTION TOT AL CUMULATIVE CATEGORY OF EXPENDITURE AMOUNT OF THIS REQUEST PAYMENTS Neighboring County Collection 75% of total cost Salaries $ $ Fringe Benefits $ $ Contractual Services $ $ Supplies $ $ Miscellaneous $ $ Travel $ $ Host County Allocation Up to $1 OK/county Salaries $ $ Fringe Benefits $ $ Contractual Services $ $ Supplies $ $ Miscellaneous $ $ Travel (if authorized) $ $ Equipment (if authorized) $ $ TOTAL AMOUNT $ $ AGREEMENT AMOUNT $ Less Total Cumulative Payments of: $ TOTAL REMAINING IN GRANT $ GRANTEE CERTIFICATION The undersigned certifies that the amount being requested for reimbursement above was for items that were charged to and utilized on 1y tior th e ab ove cite . d grant act1v1t1es. Grantee's Grant Manager's Grantee's Fiscal Agent Signature Print Name Print Name Telephone Number Telephone Number DEP Agreement No. S0717, Attachment B, Page I of 2  INSTRUCTIONS FOR COMPLETING ATT AC HM ENT B PAYMENT REQUEST SUMMARY FORM GRANTEE: Enter the name of the Grantee's agency. MAILING ADDRESS: Enter the address that you want the state warrant mailed to. DEP AGREEMENT NO.: This is the number identified on the first page of this Agreement. DATE OF REQUEST: This is the date you are submitting the request. AMOUNT REQUESTED: This should match the amount on the "TOTAL AMOUNT" line for the "AMOUNT OF THIS REQUEST' column. GRANTEE'S GRANT MANAGER: This should be the person identified as grant manager in this Agreement. PAYMENT REQUEST NO.: This is the number of your payment request, not the quarter number. NEIGHBORING COUNTY: A separate Payment Request Summary Form must be submitted for each neighboring county under this Agreement, identify the neighboring county for this payment request. GRANT EXPENDITURES SUMMARY SECTION: "AMOUNT OF THIS REQUEST" COLUMN: Enter the amount that was expended for the deliverable for which you are requesting reimbursement. This must agree with the budget category as in the currently approved budget in the current Grant Work Plan of this Agreement. Do not claim expenses in a budget category that does not have an approved budget. Do not claim items that are not specifically identified in the current Grant Work Plan. Enter the column total on the "TOTAL AMOUNT' line. Enter the amount of the Agreement on the "AGREEMENT AMOUNT' line. Enter the total cumulative amount of this request and all previous payments on the "LESS TOTAL CUMULATIVE PAYMENTS OF' line. Deduct the "LESS TOTAL CUMULATIVE PAYMENTS OF' from the "AGREEMENT AMOUNT' for the amount to enter on the "TOTAL REMAINING JN GRANT' line. "TOT AL CUMULATIVE PAYMENTS" COLUMN: Enter the cumulative amounts that have been claimed to date for reimbursement by budget category. The final report should show the total of all payments; first through the final payment (this amount cannot exceed the approved budget amount for that budget category). Enter the column total on the "TOTALS" line. Do not enter anything in the shaded areas. GRANTEE CERTIFICATION: Must be signed by both the Grantee's Grant Manager as identified in the grant agreement and the Grantee's Fiscal Agent. NOTE: If claiming reimbursement for travel, you must include copies of receipts and a copy of the travel reimbursement form approved by the Department of Financial Services, Chief Financial Officer. DEP Agreement No. S0717, Attachment B, Page 2 of 2