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1.
⑨
2.
3.
4.
⑬
5.
a. b.
⑭ ⑮
$ $
$ $
$ $$ $
$ $
$ $
$ $
$ $
6. a. $
b. $
c. $
d. $e. $
f. $
7.
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10. ⑳
GRANTEE:
STATE APPROVAL: ⑲ DATE:
⑱ DATE:
SIGNATURE (Authorized Representative)
SUBMIT REQUEST TO: CALIFORNIA DEPARTMENT OF PARKS AND RECREATION
OFF-HIGHWAY MOTOR VEHICLE RECREATION DIVISION
ATTENTION: (NAME OF GRANT ADMINISTRATOR)
1725 23rd STREET, SUITE 200
SACRAMENTO, CA 95816-7100
PAYMENT REQUEST
CATEGORY AMOUNT
include supporting documentation for the prior advance. Note: Advance requests may not exceed the need for the advance and a list of planned expenditures. Subsequent advance requests must
All advance requests except Law Enforcement projects must include a written justification explaining
half the total grant amount.
①
ATTENTION . . . . . . . . . . . . . . .
CERTIFICATION: I represent and warrant that I have full authority to execute this payment request on behalf of the Grantee. I declare under
and that all funds received have or will be expended in accordance with the conditions set forth by the State.
penalty of perjury that the information provided on this form and any accompany documents are true and correct to the best of my knowledge
REMAINING GRANT FUNDS AVAILABLE (6c minus 6d) . . .
TOTAL AMOUNT APPLIED TO MATCH TO DATE . . . . . . . .
SEND WARRANT TO: AGENCY NAME . . . . . . . . . . . . ⑰STREET ADDRESS / P.O. BOX
CITY . . . . . . . . . . . . . . . . . . . . . STATE: ZIP CODE:
PAYMENT INFORMATION: TOTAL GRANT AMOUNT . . . . . . . . . . . . . . . . . . . . . . . . . . . ⑯
TOTAL REIMBURSEMENT / ADVANCE TOTAL MATCH
REIMBURSEMENT / ADVANCE REQUESTED TO DATE . . .
CURRENT AMOUNT AVAILABLE (6a minus 6b) . . . . . . . . . .
REIMBURSEMENT / ADVANCE AMOUNT (From step 5a) . .
Equipment Use Expenses Equipment Use Expenses
Equipment Purchases Equipment Purchases
Other Other
Indirect Costs Indirect Costs
CATEGORY AMOUNT
Staff Staff
Contracts Contracts
Materials / Supplies Materials / Supplies
⑨ (Check box if FINAL) Final payment requests must be submitted
within 120 days after the completion of the project or end of the
project performance period, whichever comes first.
⑩
⑪ ⑪
All supporting documents for reimbursement costs claimed must be attached.
PROJECT EXPENDITURE AND MATCH DOCUMENTATION SUBMITTED FOR THIS REQUEST:
Amount to be REIMBURSED / ADVANCED: Amount applied to MATCH requirement:
PAYMENT REQUEST
Complete the following with the information from the Project Agreement:
② ③ ④
⑤
⑥ ⑦
⑧ ⑧
PROJECT AGREEMENT NUMBER: CONTRACT NUMBER: PCA: STATUTES:
GRANTEE:
PROJECT TITLE: VENDOR NUMBER:
PROJECT PERFORMANCE PERIOD: FROM: TO:
PAYMENT REQUEST NUMBER: FINAL
INVOICE NUMBER / BILL FOR COLLECTION NUMBER (For Grantee use):
PAYMENT REQUEST PERIOD: FROM: TO:
PAYMENT REQUEST TYPE (Check one):
ADVANCE ⑫
REIMBURSEMENT
State of California - Natural Resources Agency DEPARTMENT OF PARKS AND RECREATION
OFF-HIGHWAY MOTOR VEHICLE RECREATION DIVISION
GRANTS AND COOPERATIVE AGREEMENTS PROGRAM
DPR 364 (Rev. 2/2015) (Excell 2/20/2015)
Staff Costs
(Enter Agency Name & Project # Here)
(Enter Reporting Period Here)
Date Employee Employee ID Unit Hours Worked Unit Cost Amt applied to Match Amt applied to Grant
7-7-13 Barnney Five OHV67 7 $48.75 $341.25
7-7-13 Bertha Betcha OHV89 12 $39.80 $477.60
7-7-13 Gomer Pyle OHV45 10 $35.00 $350.00
7-7-13 Lilly Ringy Dingy OHV51 8 $42.35 $338.80
7-9-13 Barnney Five OHV67 8 $48.75 $341.25
7-9-13 Barnney Five OHV67 8 $48.75 $341.25
7-28-13 Barnney Five OHV67 8 $48.75 $341.25
7-31-13 Bertha Betcha OHV89 9 $39.80 $358.29
8-12-13 Lilly Ringy Dingy OHV51 6 $42.35 $254.10
8-15-13 Lilly Ringy Dingy OHV51 7 $42.35 $296.45
8-23-13 Lilly Ringy Dingy OHV51 8 $42.35 $338.80
8-23-13 Gomer Pyle OHV45 10 $35.00 $350.00
8-29-13 Gomer Pyle OHV45 10 $35.00 $350.00
8-29-13 Gomer Pyle OHV45 10 $35.00 $350.00
8-29-13 Gomer Pyle OHV45 10 $35.00 $350.00
9-9-13 Bertha Betcha OHV89 8 $39.80 $318.40
9-9-13 Bertha Betcha OHV89 8 $39.80 $318.40
9-17-13 Lilly Ringy Dingy OHV51 10 $42.35 $423.50
9-17-13 Gomer Pyle OHV45 8 $35.00 $280.00
9-22-13 Lilly Ringy Dingy OHV51 10 $42.35 $423.50
9-30-13 Bertha Betcha OHV89 7 $39.80 $278.60
9-30-13 Bertha Betcha OHV89 5 $39.80 $199.00
Total 187 $3,440.24 $3,980.20
Equipment Use Expenses
(Enter Agency Name & Project # Here)
(Enter Reporting Period Here)
Date Vehicle ID # Vehicle Make & Model Description Miles Mileage Rate Match Amount Grant Amount
5/5/13 23 Ford F-250 1FTSX21RX8EE54851 58 0.55 $31.90
5/8/13 23 Ford F-250 1FTSX21RX8EE54851 125 0.55 $68.75
5/8/13 16 Chevy Silverado 2500 1HTFX22GH7AA3221 79 0.55 $43.45
5/16/13 16 Chevy Silverado 2500 1HTFX22GH7AA3221 89 0.55 $48.95
5/17/13 Fleet Fuel Purchase OHV Equipment N/A N/A $3,000.00
5/28/13 V-2 Dodge Ram 2MNNV18KL9BB12341 102 0.55 $56.10
6/1/13 16 Chevy Silverado 2500 1HTFX22GH7AA3221 15 0.55 $8.25
6/2/13 16 Chevy Silverado 2500 1HTFX22GH7AA3221 110 0.55 $60.50
6/13/13 V-2 Dodge Ram 2MNNV18KL9BB12341 68 0.55 $37.40
6/6/13 6 Jeep Cherokee 2LOPN33CD0EE4567 45 0.55 $24.75
6/7/13 6 Jeep Cherokee 2LOPN33CD0EE4567 39 0.55 $21.45
6/7/13 6 Jeep Cherokee 2LOPN33CD0EE4567 96 0.55 $52.80
6/16/13 23 Ford F-250 1FTSX21RX8EE54851 81 0.55 $44.55
6/21/13 23 Ford F-250 1FTSX21RX8EE54851 100 0.55 $55.00
6/22/13 23 Ford F-250 1FTSX21RX8EE54851 105 0.55 $57.75
6/28/13 16 Chevy Silverado 2500 1HTFX22GH7AA3221 150 0.55 $82.50
6/30/13 16 Chevy Silverado 2500 Transmission Repair N/A N/A $2,000.00
7/4/13 V-2 Dodge Ram 2MNNV18KL9BB12341 87 0.55 $47.85
7/5/13 V-2 Dodge Ram 2MNNV18KL9BB12341 113 0.55 $62.15
7/6/13 V-2 Dodge Ram 2MNNV18KL9BB12341 120 0.55 $66.00
Total 1582 $3,507.10 $2,363.00
Alpine Watershed Group – G13-04-76-R01
September 1, 2015 to June 30, 2016
Statement of Activities
Summary
Starting in the fall of 2015, the Alpine Watershed Group (AWG) began on-the-ground
implementation for the East Carson River Restoration Project under this grant from the
California Department of Off-Highway Vehicle Recreation. AWG worked with partnering
land agencies to finalize the specific restoration applications for each site. Here is a
summary of meetings and site visits during this reporting period:
• USFS design and strategy meetings - onsite - 1/28/16; office - 3/16/16
• BLM design meetings - 3/15/16, 4/14/16
• Contractor only meeting - 3/17/16, 3/29/16
Project Work Conducted
Project work was completed in three phases with specific sites being addressed in each
phase. Here is an overview of each phase:
Phase 1: Friday, Sept 25 - Friday, Oct 2 ··
• Material staging: Boulder collection and delivery to main staging area -20 truckloads
• 2 sites completed: Kurtz Mill Flatt, White Gate
Phase 2: Monday April 4- Friday April 8
• 3 sites completed: Monitor, Silver Hill, Buried Pine
• 1 site started: Cottonwood
Phase 3: Monday, April 18 -Friday, April 29
• 1 site completed -Hangman's Bridge
Here is a breakdown of the specific work accomplished at each site:
Site #1: Hangman's Bridge
• # barriers placed -2 metal barricades & 10 rocks
• # feet of fencing replaced - 70
• Square footage of area excluded from OHV use -3,300
Next steps: hillside stabilization with seed andjute matting
Site #7: Kurtz Mill Flatt
• # barriers placed -20 rocks
• # camp areas enhanced - 1
• # river accesses blocked - 2
• Square footage of area excluded from OHV use - 20,000
• # willows planted - 130
Site #9: White Gate
• # Feet road closed -330 linear feet
• # barriers placed - 45 rocks
• # river accesses blocked - 1
• Square footage of area excluded from OHV use - 6,875 (road, camping, river
access; 3,575 not including the road)
• # willows planted - 80
Alpine Watershed Group – G13-04-76-R01
September 1, 2015 to June 30, 2016
Monitoring and Volunteer Events
• Pre & post photos taken of each completed site (attached)
• Water quality data collected on 3 days (9/13/15, 3/12/16 and 6/12/16) by 2 volunteers
• Creek Day - September 12, 2015 - 5 community volunteers and 3 California Conservation
Corps crews (specifically 36 corps members) participated in revegetation and trash
cleanup at 2 sites
Outreach
Updates regarding this project were given to the following entities or at certain events:
• Alpine County Board of Supervisors - 8/18/2015
• AWG Board of Directors - 11/10/16, 5/10/16
• Carson Water Subconservancy District - 1/20/16
• Fish and Game Commission - 4119/2016
• Sierra Nevada Alliance Conference - 11/26/15
Other outreach included Facebook updates and one article "Restoration Begins on the East
Fork of the Carson River" printed in the Watershed Connections newsletter of the Carson
Water Subconservancy District (attached).
Pre and Post Implementation Photos East Fork of the Carson River Restoration Project
Alpine Watershed Group CDPR OHV Grant #G13-04-76-R01
BLM Site #1: Hangman’s Bridge
WGS UTMs
38°41'24.16" N 119°45'54.28" W
Figure 1. Hangman's Bridge hillside access pre restoration
Figure 2. Hangman's Bridge hillside access post restoration
East Fork of the Carson River Restoration Project Alpine Watershed Group - #G13-04-76-R01
10 | P a g e
USFS #7: Kurtz Mill Flatt WGS UTMs 38°39'42.39" N 119°43'40.93" W
Figure 19. Kurtz Flatt river access OHV road pre restoration
Figure 20. Kurtz Flatt river access OHV road post restoration
East Fork of the Carson River Restoration Project Alpine Watershed Group - #G13-04-76-R01
11 | P a g e
USFS Site #9: White Gate WGS UTMs 38°40'45.72" N 119°44'45.53" W
Figure 21. White Gate decommissioned OHV road pre restoration
Figure 22. White Gate decommissioned OHV road post restoration
PROJECT EXPENDITURE AND MATCH DOCUMENTATION SUBMITTED FOR THIS PAYMENT REQUEST:
Grant #: G15-XX-XX-G01 PR 1
Amount to be REIMBURSED: Amount to be applied to MATCH requirements:
CATEGORY AMOUNT CATEGORY AMOUNT
Staff 9,127.52$ Staff 3,000.00$
Contracts 3,000.00$ Contracts -$
Materials / Supplies 2,000.00$ Materials / Supplies -$
Equipment Use Expense 275.00$ Equipment Use Expense -$
Equipment Purchase 15,200.00$ Equipment Purchase 2,500.00$
Other -$ Other -$
Indirect Costs 487.00$ Indirect Costs -$
TOTAL REIMBURSEMENT 30,089.52$ TOTAL MATCH 5,500.00$
NOTES:
NOTE: Except for the three fields 'Grant #', 'PR#' and 'Notes', this form is locked and linked to tabs two, three, and four. Please enter the Grant Number and Payment Request number (PR) in the red outlined fields as they will carry over to the other
Form rev 12/30/15
G15-XX-XX-G01 PR - 1 GRANT Charges
Staff Chgs ContractsMatls &
Suppl
Equip Use
ExpenseEquip Purch Other
Indirect
CostsNotes
Numbers are for example only, delete and enter your own numbers:
50.00$ Lewis Smith
1,858.50$ Lewis Smith
6,784.14$ Taj Carter
434.88$ Ron TottenInsert
add'l 3,000.00$ Toilet Pumping
rows
as 500.00$ Ace Hardware
needed. 1,500.00$ Meeks Lumber
275.00$ mileage @ .55
15,200.00$ ROV Purchase
487.00$ Utilities
Grand Total:
TOTALS 9,127.52$ 3,000.00$ 2,000.00$ 275.00$ 15,200.00$ -$ 487.00$ 30,089.52$
Supporting Documentation Needed:
Staff Charges - Electronic payroll report, excel sheet breakdown, etc. Keep timesheets in case of audit.
Contracts - Copies of anything supporting the contract charges.
Materials and Supplies - Copies of receipts supporting each charge.
Equipment Use Expense - Copies of receipts for fuel and repairs, electronic report or excel sheet breakdown of vehicles used, mileage charged.
Equipment Purchase - Copies of receipts for any charge, must be $1000 or more single item cost. Submit a picture of the equipment showing "OHV Funds at Work" decal.
Other - Any charge for anything that doesn't fit in the other categories, advertising, travel, etc. Copies of receipts supporting charge.
Indirect Costs - Limited to 15% of total of grant amount, provide explanation of what comprised the Indirect Cost charge.
Remember - Overall, any charge claimed MUST be relative to the Contract/Project Agreement Cost Estimate.
Totals line is linked to the Summary and to the Payment Request
G15-XX-XX-G01 PR - 1 MATCH Charges
Staff Chgs ContractsMatls &
Suppl
Equip Use
ExpenseEquip Purch Other
Indirect
CostsNotes
Numbers are for example only, delete and enter your own numbers
3,000.00$ Volunteers
2,500.00$ ROV Trailer
Insert
add'l
rows
as
needed.
Grand Total:
TOTALS 3,000.00$ -$ -$ -$ 2,500.00$ -$ -$ 5,500.00$
Supporting Documentation Needed:
Staff Charges - Electronic payroll report, excel sheet breakdown, etc. Keep timesheets in case of audit.
Contracts - Copies of anything supporting the contract charges.
Materials and Supplies - Copies of receipts supporting each charge.
Equipment Use Expense - Copies of receipts for fuel and repairs, electronic report or excel sheet breakdown of vehicles used, mileage charged.
Equipment Purchase - Copies of receipts for any charge, must be $1000 or more single item cost. Submit a picture of the equipment showing "OHV Funds at Work" decal.
Other - Any charge for anything that doesn't fit in the other categories, advertising, travel, etc. Copies of receipts supporting charge.
Indirect Costs - Limited to 15% of total of grant amount, provide explanation of what comprised the Indirect Cost charge.
Remember - Overall, any charge claimed MUST be relative to the Contract/Project Agreement Cost Estimate.
Totals line is linked to the Summary and to the Payment Request
1.
2.
3.
4.
5.
a. b.
$ $$ $$ $$ $$ $$ $$ $
$ $
6. a. $b. $c. $
d. $e. $f. $
7.
8.
9.
10. SUBMIT REQUEST TO: CALIFORNIA DEPARTMENT OF PARKS AND RECREATION
OFF-HIGHWAY MOTOR VEHICLE RECREATION DIVISION
ATTENTION: <Name of your Grant Adminstrator>
1725 23rd STREET, SUITE 200SACRAMENTO, CA 95816-7100
STATE APPROVAL: DATE:
and that all funds received have or will be expended in accordance with the conditions set forth by the State.
GRANTEE: DATE:
SIGNATURE (Authorized Representative)
ATTENTION . . . . . . . . . .
CERTIFICATION: I represent and warrant that I have full authority to execute this payment request on behalf of the Grantee. I declare under
penalty of perjury that the information provided on this form and any accompany documents are true and correct to the best of my knowledge
STREET ADDRESS /
CITY . . . . . . . . . . . . . . . . STATE: ZIP CODE:
REMAINING GRANT FUNDS AVAILABLE (6c minus 6d) . . . 44,910.48 TOTAL AMOUNT APPLIED TO MATCH TO DATE . . . . . . . .
SEND WARRANT TO:
AGENCY NAME . . . . . .
. . . . . .
REIMBURSEMENT / ADVANCE REQUESTED TO DATE . . .
CURRENT AMOUNT AVAILABLE (6a minus 6b) . . . . . . . . . . 75,000.00 REIMBURSEMENT / ADVANCE AMOUNT (From step 5a) . . 30,089.52
TOTAL REIMBURSE/ ADVANCE 30,089.52 TOTAL MATCH 5,500.00 PAYMENT
INFORMATION: TOTAL GRANT AMOUNT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75,000.00
Other - Other - Indirect Costs 487.00 Indirect Costs -
Equipment Use Expenses 275.00 Equipment Use - Equipment Purchases 15,200.00 Equipment Purchases 2,500.00
Contracts 3,000.00 Contracts - Materials / Supplies 2,000.00 Materials / Supplies -
CATEGORY AMOUNT CATEGORY AMOUNTStaff 9,127.52 Staff 3,000.00
include supporting documentation for the prior advance. Note: Advance requests may
half the total grant amount.
All supporting documents for reimbursement costs claimed must be attached.
PROJECT EXPENDITURE AND MATCH DOCUMENTATION SUBMITTED FOR THIS REQUEST:
Amount to be REIMBURSED / ADVANCED: Amount applied to MATCH requirement:
All advance requests except Law Enforcement projects must include a written the need for the advance and a list of planned expenditures. Subsequent advance
1 (Check box if FINAL) Final payment requests must be
submitted within 120 days after the completion of the
project or end of the project performance period, whichever
comes first.
G15-XX-XX-G01
PAYMENT REQUESTPAYMENT REQUEST
Complete the following with the information from the Project Agreement:
PROJECT AGREEMENT NUMBER: CONTRACT NUMBER: PCA: STATUTES:
GRANTEE:
PROJECT TITLE: VENDOR NUMBER:
PROJECT PERFORMANCE PERIOD: FROM: TO:
PAYMENT REQUEST NUMBER: FINAL
INVOICE NUMBER / BILL FOR COLLECTION NUMBER (For Grantee use):
PAYMENT REQUEST PERIOD: FROM: TO:
PAYMENT REQUEST TYPE (Check one):
ADVANCE
REIMBURSEMENT
State of California - Natural Resources Agency DEPARTMENT OF PARKS AND RECREATION
OFF-HIGHWAY MOTOR VEHICLE RECREATION DIVISION GRANTS AND COOPERATIVE AGREEMENTS PROGRAM
NOTE: Data needed for these fields is found on your Project Agreement.
NOTE: Data fields are locked and linked to the numbers on the Summary.
Enter Total Grant Award amt
Enter amount total from prior PRs
Enter dates covered by this PR. Include a Project Status Report with this PR describing the activity that occurred on the project during this time period.
Enter Total match submitted
PR number field is locked and linked to the Summary sheet.
DPR 364 (Rev. 2/2015) (Excell 2/20/2015)
Form rev 2/16/16
OHV GRANT PROJECT EXPENDITURE AND MATCH DOCUMENTATION SUBMITTED FOR CLOSEOUT:
Grant #: GX-XX-XX-XXX
Total Amount Reimbursed: Total Amount submitted for MATCH: Total Project Costs:
CATEGORY AMOUNT CATEGORY AMOUNT CATEGORY AMOUNT
Staff 27,373.89$ Staff 31,109.89$ Staff 58,483.78$
Contracts 53,431.25$ Contracts 6,691.25$ Contracts 60,122.50$
Materials / Supplies 4,834.30$ Materials / Supplies 4,331.88$ Materials / Supplies 9,166.18$
Equipment Use Expense 4,385.92$ Equipment Use Expense 3,100.88$ Equipment Use Expense 7,486.80$
Equipment Purchase 21,000.00$ Equipment Purchase 10,003.00$ Equipment Purchase 31,003.00$
Other 350.00$ Other 710.00$ Other 1,060.00$
Indirect Costs 8,198.75$ Indirect Costs 565.73$ Indirect Costs 8,764.48$ TOTAL Reimbursement 119,574.11$ TOTAL MATCH 56,512.63$ TOTAL COSTS 176,086.74$
NOTES:
Minimum Match Required: 25%
Final Grant/Match Percentage:
Grant 119,574.11$ 67.9% Total Indirect Costs 7.87%Match 56,512.63$ 32.1% (total IC / total grant no IC only)
Total Project Cost 176,086.74$ 100.0% (Maximum allowable = 15%)Max Indirect Cost amt: 16,706.30$
Minimum Match Required 39,858.04$
(based upon Total Reimbursmement)
NOTE: Except for the three fields 'Grant #', 'Notes', and match percentage, this form is locked and linked to tabs two and three. Please enter the Grant Number and Minimum Match percentage in the red outlined fields.
GX-XX-XX-XXX GRANT Charges
Staff Chgs Contracts
Matls
SuppliesEquip Use
Expense Equip Purch Other
Indirect
Costs Total
PR1: 1,958.15$ 293.72$ 2,251.87$
PR2: 2,209.44$ 331.42$ 2,540.86$
PR3: 2,973.02$ 445.95$ 3,418.97$
PR4: 2,102.27$ 315.34$ 2,417.61$
PR5: 10,625.17$ 13,563.75$ 658.38$ 2,185.35$ 350.00$ 27,382.65$
PR6: 1,890.79$ 25,935.00$ 2,111.62$ 1,563.33$ 31,500.74$
PR7: 514.44$ 5,897.50$ 185.00$ 350.00$ 1,042.04$ 7,988.98$
PR8: 766.86$ 2,037.50$ 21,000.00$ 3,493.12$ 27,297.48$
PR9: 1,727.54$ 5,997.50$ 30.20$ 145.19$ 1,185.06$ 9,085.49$
PR10: 2,606.21$ 2,034.10$ 307.05$ 742.10$ 5,689.46$
PR11: -$
PR12: -$
PR13: -$
PR14: -$
Grand Total:
TOTALS 27,373.89$ 53,431.25$ 4,834.30$ 4,385.92$ 21,000.00$ 350.00$ 8,198.75$ 119,574.11$
NOTE: Enter data from each previous payment request by category here.
GX-XX-XX-XXX MATCH Charges
Staff Chgs Contracts
Matls
SuppliesEquip Use
Expense Equip Purch Other
Indirect
Costs Total
PR1: 2,028.39$ 549.99$ 1,094.56$ 3,672.94$
PR2: 2,481.95$ 372.29$ 2,854.24$
PR3: 1,303.74$ 94.30$ 1,398.04$
PR4: 4,533.68$ 4,653.75$ 1,209.60$ 381.43$ 10,778.46$
PR5: 8,501.08$ 2,111.62$ 560.00$ 11,172.70$
PR6: 4,669.80$ 1,352.73$ 6,022.53$
PR7: 904.67$ 2,037.50$ 127.55$ 10,003.00$ 13,072.72$
PR8: 6,346.20$ 97.89$ 150.00$ 193.44$ 6,787.53$
PR9: 340.38$ 362.78$ 50.31$ 753.47$
PR10: -$
PR11: -$
PR12: -$
PR13: -$
PR14: -$
Grand Total:
TOTALS 31,109.89$ 6,691.25$ 4,331.88$ 3,100.88$ 10,003.00$ 710.00$ 565.73$ 56,512.63$
Minimum Match req'd 39,858.04$
16,654.59$
NOTE: Enter data from each previous payment request by category here.
FINAL PROJECT REVIEW
16-17 Closeout wkbk example
1. Date:2. Grantee:3. Project Agreement Number4. Project Type:5. Project Performance Period (Original): to:
6. Amendment(s): No Yes If 'Yes', how many ? Time Extension Amended End Date: Description
7. Project Contract Amount: $
8. Minimum Match Required: 25% $$
No Yes
9. Payment Type: Reimbursement Advance$ $$ $
$$
10.
11. Final documents submitted: Report of deliverables completed All documents supporting expenditures (including match) A summary of project costs (including match) For those projects in which a report was part of the Project Agreement, two (2) copies of the repo For all sub-contracted work, a Notice of Completion
12. How many miles of trail/road maintained or land restored? or acres:
13. Did the project have "Ground Disturbing Activity" No Yes If 'Yes', attach soil report.
14 Was habitat monitoring done during the project? No Yes If 'Yes', attach results.
15. Were pictures provided? No Yes If 'Yes', attach pictures.
16. List all scope items not completed (or provide an attachment):
Grant Administrator: Date:Trail Coordinator (If soil report required): Date:HMP Reviewed: Date:Grants Manager: Date:
GX-XX-XX-XXX
from:
Type of Amendment:
Remaining Funds: -119,574.11
39,858.04Total Match Submitted: 56,512.63
Match Requirement Met?
Total Payments Made: 119,574.11
Actual Expenditures Reimbursed:Refund Amount Due:
If Remaining Funds in Item #9. are greater than, $10,000, provide reason: