Instructions for Attachment C "Payment Request Form" - Florida

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DEPARTMENT OF ENVIRONMENTAL PROTECTION
FLORIDA COASTAL MANAGEMENT PROGRAM
INSTRUCTIONS FOR COMPLETING
ATTACHMENT C
PAYMENT REQUEST FORM
GRANTEE: Enter the name of the grantee’s agency.
MAILING ADDRESS: Enter the address that you want the state warrant sent.
DEP AGREEMENT NO.: This is the number on your grant agreement that starts with CM _ _.
DATE OF REQUEST: This is the date you are submitting the report.
TOTAL AMOUNT REQUESTED: This should match the amount on the “TOTAL AMOUNT” line for the
“AMOUNT OF THIS CLAIM” column.
GRANTEE’S GRANT MANAGER: This should be the person identified as grant manager in the grant agreement.
PAYMENT REQUEST NO.: This is the number of your payment request, not the quarter number.
PERFORMANCE PERIOD: This is the beginning and ending date of the reporting period.
DELIVERABLE NO.: Enter the number of the DELIVERABLE(S) that you are requesting payment for.
GRANT EXPENDITURES SUMMARY SECTION:
“AMOUNT OF THIS REQUEST” COLUMN: Enter the amount that was paid out for all listed deliverables during
the invoice period for which you are requesting reimbursement. This must be by budget category as in the currently
approved budget in Attachment A, Project Work Plan, or amendment of your grant 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 Budget Narrative section of Attachment A. DO NOT ALTER FORM OR COMBINE
BUDGET CATEGORIES. Enter the column total on the “TOTAL AMOUNT” line. Enter the FCMP budget amount
on the “GRANT BUDGET 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 “GRANT BUDGET AMOUNT” for the amount to enter on the “REMAINING BUDGET IN
GRANT” line.
“TOTAL CUMULATIVE FCMP CLAIMS” COLUMN: Enter the cumulative amounts that have been claimed to
date for FCMP expenses by budget category. The final report should show the total of all claims, first claim through
the final claim, etc. Enter the column total on the “TOTAL AMOUNT” line. DO NOT ENTER ANYTHING IN
THE SHADED AREAS.
“MATCHING FUNDS CLAIMED” COLUMN: Enter the amount to be claimed as match for the reporting period.
This needs to be shown under specific budget categories according to what is in the currently approved Attachment A,
Project Work Plan. Enter the total on the “TOTAL AMOUNT” line for this column. Enter the match budget amount
on the “GRANT BUDGET AMOUNT” line for this column. Enter the total cumulative amount of this and any previous
match claimed on the “LESS TOTAL CUMULATIVE PAYMENTS OF” line for this column. Deduct the “LESS
TOTAL CUMULATIVE PAYMENTS OF” from the “GRANT BUDGET AMOUNT” for the amount to enter on the
“REMAINING BUDGET IN GRANT” line.
“TOTAL CUMULATIVE MATCHING FUNDS” COLUMN: Enter the cumulative amount you have claimed to
date for match by budget category. Put the total of all on the line titled “TOTAL AMOUNT.” The final report should
show the total of all claims, first claim through the final claim, etc. DO NOT ENTER ANYTHING IN THE
SHADED AREAS.
GRANTEE CERTIFICATION: Must have the original signature of both the Grantee’s Grant Manager and
the Grantee’s Fiscal Agent as identified in the grant agreement.
REQUIRED BACK-UP DOCUMENTATION:
Exhibit I - Schedule of Invoices for Reimbursement for each deliverable.
Exhibit II - Schedule of Match for each deliverable.
Copies of Invoices (Not applicable to state agencies)
Copies of canceled checks (Not applicable to state agencies)
Copies of Travel Reimbursements if applicable
DEPARTMENT OF ENVIRONMENTAL PROTECTION
FLORIDA COASTAL MANAGEMENT PROGRAM
INSTRUCTIONS FOR COMPLETING
ATTACHMENT C
PAYMENT REQUEST FORM
GRANTEE: Enter the name of the grantee’s agency.
MAILING ADDRESS: Enter the address that you want the state warrant sent.
DEP AGREEMENT NO.: This is the number on your grant agreement that starts with CM _ _.
DATE OF REQUEST: This is the date you are submitting the report.
TOTAL AMOUNT REQUESTED: This should match the amount on the “TOTAL AMOUNT” line for the
“AMOUNT OF THIS CLAIM” column.
GRANTEE’S GRANT MANAGER: This should be the person identified as grant manager in the grant agreement.
PAYMENT REQUEST NO.: This is the number of your payment request, not the quarter number.
PERFORMANCE PERIOD: This is the beginning and ending date of the reporting period.
DELIVERABLE NO.: Enter the number of the DELIVERABLE(S) that you are requesting payment for.
GRANT EXPENDITURES SUMMARY SECTION:
“AMOUNT OF THIS REQUEST” COLUMN: Enter the amount that was paid out for all listed deliverables during
the invoice period for which you are requesting reimbursement. This must be by budget category as in the currently
approved budget in Attachment A, Project Work Plan, or amendment of your grant 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 Budget Narrative section of Attachment A. DO NOT ALTER FORM OR COMBINE
BUDGET CATEGORIES. Enter the column total on the “TOTAL AMOUNT” line. Enter the FCMP budget amount
on the “GRANT BUDGET 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 “GRANT BUDGET AMOUNT” for the amount to enter on the “REMAINING BUDGET IN
GRANT” line.
“TOTAL CUMULATIVE FCMP CLAIMS” COLUMN: Enter the cumulative amounts that have been claimed to
date for FCMP expenses by budget category. The final report should show the total of all claims, first claim through
the final claim, etc. Enter the column total on the “TOTAL AMOUNT” line. DO NOT ENTER ANYTHING IN
THE SHADED AREAS.
“MATCHING FUNDS CLAIMED” COLUMN: Enter the amount to be claimed as match for the reporting period.
This needs to be shown under specific budget categories according to what is in the currently approved Attachment A,
Project Work Plan. Enter the total on the “TOTAL AMOUNT” line for this column. Enter the match budget amount
on the “GRANT BUDGET AMOUNT” line for this column. Enter the total cumulative amount of this and any previous
match claimed on the “LESS TOTAL CUMULATIVE PAYMENTS OF” line for this column. Deduct the “LESS
TOTAL CUMULATIVE PAYMENTS OF” from the “GRANT BUDGET AMOUNT” for the amount to enter on the
“REMAINING BUDGET IN GRANT” line.
“TOTAL CUMULATIVE MATCHING FUNDS” COLUMN: Enter the cumulative amount you have claimed to
date for match by budget category. Put the total of all on the line titled “TOTAL AMOUNT.” The final report should
show the total of all claims, first claim through the final claim, etc. DO NOT ENTER ANYTHING IN THE
SHADED AREAS.
GRANTEE CERTIFICATION: Must have the original signature of both the Grantee’s Grant Manager and
the Grantee’s Fiscal Agent as identified in the grant agreement.
REQUIRED BACK-UP DOCUMENTATION:
Exhibit I - Schedule of Invoices for Reimbursement for each deliverable.
Exhibit II - Schedule of Match for each deliverable.
Copies of Invoices (Not applicable to state agencies)
Copies of canceled checks (Not applicable to state agencies)
Copies of Travel Reimbursements if applicable
FLAIR Report (State agencies only)
Copies of Volunteer Logs (if applicable)
NOTE: If claiming reimbursement for travel, you must include copies of receipts and a copy of the travel
reimbursement form (available from staff of the Florida Coastal Management Program or use your affiliation’s
reimbursement form, provided it has been approved by the Comptroller’s Office of the State of Florida).
PAYMENT WILL BE BASED ON COMPLETION OF DELIVERABLES: Deliverables
**
must be submitted and approved prior to payment
**
Questions regarding completion of the Payment Request Form should be directed to the Department’s Grant Manager,
identified in the Contracts section of this Agreement.
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