Form FDACS-02019 "Subrecipient Payment Request Summary Form" - Florida

Form FDACS-02019 is a Florida Department of Agriculture and Consumer Services form also known as the "Subrecipient Payment Request Summary Form". The latest edition of the form was released in March 1, 2016 and is available for digital filing.

Download a fillable PDF version of the Form FDACS-02019 down below or find it on Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-02019 "Subrecipient Payment Request Summary Form" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Administration
SUBRECIPIENT PAYMENT REQUEST SUMMARY FORM
ADAM H. PUTNAM
COMMISSIONER
Date of Request:
Subrecipient Agreement #:
Billing Period:
Federal FAIN:
Payment Request #
Subrecipient
Subrecipient FEIN:
Subrecipient Agreement Manager
Name:
Name:
Address:
Email:
City, State, Zip + 4:
Phone:
Amount of this
Total Cumulative
Total Cumulative
Approved Budget
Matching Funds
Category of Expenditure
Request
Payments
Matching Funds
Personnel
$ 0.00
Fringe Benefits
$ 0.00
Travel (if authorized)
$ 0.00
Equipment (if authorized)
$ 0.00
Supplies
$ 0.00
Contractual (if authorized)
$ 0.00
Other Expenses
$ 0.00
Total Direct Charges
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
Indirect Charges
$ 0.00
Total Amount
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
Total Budget Amount
Agreement Period:
$ 0.00
$ 0.00
Less Total Cumulative Payments
Total Remaining in Agreement
$ 0.00
All supporting documents for the expenditures must be attached in accordance with the subrecipient agreement.
I certify to the best of my knowledge that all expenditures are for the appropriate purpose, in accordance with all applicable laws, rules and regulations
applicable to expenditures of federal funds, and in accordance with the agreements set forth in the application and award document.
Subrecipient Grant Manager's Signature
Print Name
Date
FDACS-02019 03/16
Florida Department of Agriculture and Consumer Services
Division of Administration
SUBRECIPIENT PAYMENT REQUEST SUMMARY FORM
ADAM H. PUTNAM
COMMISSIONER
Date of Request:
Subrecipient Agreement #:
Billing Period:
Federal FAIN:
Payment Request #
Subrecipient
Subrecipient FEIN:
Subrecipient Agreement Manager
Name:
Name:
Address:
Email:
City, State, Zip + 4:
Phone:
Amount of this
Total Cumulative
Total Cumulative
Approved Budget
Matching Funds
Category of Expenditure
Request
Payments
Matching Funds
Personnel
$ 0.00
Fringe Benefits
$ 0.00
Travel (if authorized)
$ 0.00
Equipment (if authorized)
$ 0.00
Supplies
$ 0.00
Contractual (if authorized)
$ 0.00
Other Expenses
$ 0.00
Total Direct Charges
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
Indirect Charges
$ 0.00
Total Amount
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
Total Budget Amount
Agreement Period:
$ 0.00
$ 0.00
Less Total Cumulative Payments
Total Remaining in Agreement
$ 0.00
All supporting documents for the expenditures must be attached in accordance with the subrecipient agreement.
I certify to the best of my knowledge that all expenditures are for the appropriate purpose, in accordance with all applicable laws, rules and regulations
applicable to expenditures of federal funds, and in accordance with the agreements set forth in the application and award document.
Subrecipient Grant Manager's Signature
Print Name
Date
FDACS-02019 03/16
SUBRECIPIENT PERSONNEL COSTS SCHEDULE
Date of Request:
Subrecipient Agreement #:
Billing Period:
Federal FAIN:
Project Hours
Hourly
Project Labor
Employee First and Last Name
Job Classification
this Period
Rate
Cost
Deliverable # and Task #
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
Total
$ 0.00
If additional lines are needed, please insert above the total line.
I hereby certify that the above listed employees worked on the project as reflected.
Subrecipient Grant Manager's Signature
Date
FDACS-02019 03/16
SUBRECIPIENT FRINGE BENEFITS COST SCHEDULE
Date of Request
Subrecipient Agreement #
Billing Period
Federal FAIN
Project Hours
Actual Fringe Benefits
Employee First and Last Name
Job Classification
this Period
Costs
Deliverable # and Task #
Total
$ 0.00
If additional lines are needed, please insert above the total line.
Please remember only actual fringe benefit costs can be charged to the grant. If you have an approved fringe rate from a federal agency, please provide
a copy of the approval letter.
I hereby certify that the above listed employees worked on the project as reflected.
Subrecipient Grant Manager's Signature
Date
FDACS-02019 03/16
SUBRECIPIENT TRAVEL COST SCHEDULE
Date of Request
Subrecipient Agreement #
Billing Period
Federal FAIN
Employee First and Last Name
Travel #
Destination
Travel Cost
Purpose of Travel
Deliverable # and Task #
Total
$ 0.00
If additional lines are needed, please insert above the total line.
Any travel expenses must have been specified in the budget plan and scope of work.
I hereby certify that the above listed travel expenses are in compliance with Section 112.061, Florida Statutes, governing payments by the State for
travel expenses.
Subrecipient Grant Manager's Signature
Date
FDACS-02019 03/16
SUBRECIPIENT EQUIPMENT COST SCHEDULE
Date of Request
Subrecipient Agreement #
Billing Period
Federal FAIN
Check
Vendor Invoice
Number and
Equipment Description
Vendor Name
Number
Date
Equipment Cost
Deliverable # and Task #
Total
$ 0.00
If additional lines are needed, please insert above the total line.
Any equipment purchases must have been specified in the budget plan and scope of work.
I hereby certify that the above listed equipment was purchase for this agreement. I hereby certify that the above listed equipment was used to
accomplish deliverables and tasks for this agreement.
Subrecipient Grant Manager's Signature
Date
FDACS-02019 03/16
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