ࡱ> {}z#` jbjbjmm hvDvvv$b"b"b"P"v#lY=n#&&&&'o((Dl<n<n<n<n<n<n<$>h/A<vo,''o,o,<&&=c0c0c0o,jR&v&l<c0o,l<c0c0V8@T"v9&# PJ[3b",<9 p;)=0Y=H9xAa-A9Av97))rc0I*\*7)7)7)<<0^7)7)7)Y=o,o,o,o,dd  INVOICE Nonpoint Source Grants Program Bureau of Land and Water Quality Maine Department of Environmental Protection Refer to reverse side of this form for instructions PROVIDER: Invoice Date:  FORMTEXT       Name:  FORMTEXT       Mail Address:  FORMTEXT       City / State / Zip:  FORMTEXT       Project ID#:  FORMTEXT       Project Title:  FORMTEXT       Total Agreement Amount: $ FORMTEXT       Use one of the following two payment methods: REIMBURSEMENT METHOD: Total Expensed to Date $ FORMTEXT       minus Prior Payments $ FORMTEXT       equals Amount this Invoice $ FORMTEXT       ADVANCE METHOD: Specify the Advance Period for which funds are needed:  FORMTEXT       months (3 months max) Prior Payments $ FORMTEXT       minus Total Expensed to Date $ FORMTEXT       equals Balance on Hand $ FORMTEXT       Projected Cash Needs $ FORMTEXT       minus Balance on Hand $ FORMTEXT       equals Amount this Invoice $  FORMTEXT       Task #Brief Explanation of Projected Cash Needs for Advance PeriodEst. Cost FORMTEXT       FORMTEXT      $ FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT      Sum of Projected Cash Needs$ FORMTEXT       NON-FEDERAL MATCH: Match Required $ FORMTEXT       minus Match to Date $ FORMTEXT       = Match Balance Remaining $ FORMTEXT       CERTIFICATION: For reimbursement, Provider certifies that grant funds were expensed on allowed activities and purposes in accordance with the Grant Agreement. For advances, Provider certifies that the requested payment is needed for expected project expenses during the advance period and that funds will be expensed on allowed activities and purposes in accordance with the Grant Agreement. Provider agrees to produce on request the source documents used to prepare this payment request. SUBMITTED BY: (signature - authorized Provider representative)  FORMTEXT       FORMTEXT       FORMTEXT       Name Printed  FORMTEXT       Title  FORMTEXT       Date:  FORMTEXT       PAYMENT APPROVED BY: (signature - DEP Agreement Administrator) _____________________________ Name Printed ______________________________ Date: ___/___/___ FOR DEP USE ONLY Date received from AA ___/___/___ Date forwarded to Admin ___/___/___ AdvantageME CT No: _______________________________________________________________________ Vendor Code ____________________ Fund _______ Agency _______ Unit _________ SubUnit __________ Object ________ Activity ________ SubActivity ________ Program ____________ Amount $_____________ Recipients of a Maine DEP Nonpoint Source Grant Use this Invoice to request payment Instructions for Completing the Invoice: Provider Info -- Date the invoice was signed by the provider. -- Provider Name and Mailing Address. -- Project ID Number (example: 2006R-12) and Project Title (refer to Agreement or project work plan). -- Total Agreement Amount. The total amount of grant funds specified in the Agreement, on page 1. Payment Method - Reimbursement or Advance -- Complete the "REIMBURSEMENT" section, if the invoice is to reimburse the Provider for funds expensed. Do not complete the "ADVANCE" section. -- Complete the "ADVANCE" section if the invoice is for an advance payment or both an advance an reimbursement. Do not complete the "REIMBURSEMENT" section. Request for Reimbursement -- Total Expensed to Date The total grant funds the Provider expensed to date for allowed project costs. -- Prior Payments. The total amount of grant funds received to date by the Provider. -- Amount this Invoice. Subtract the Prior Payments from Total Expensed to Date. Request for Advance -- "Advance Period". Specify the advance period in months, not to exceed 3 months. -- Prior Payments. The total amount of grant funds received to date by Provider. -- Total Expensed to Date. The total grant funds the Provider expensed to date for allowed project costs. -- Balance On Hand. Subtract Expended to Date from Prior Payments". -- Projected Cash Needs. 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Provide a brief explanation of anticipated work and costs in the table. -- Amount this Invoice. Subtract Balance on Hand from Projected Cash Needs. Report Non-Federal Match Used to Date -- Match Required. The amount of match shown on the budget page of the work plan. -- Match to Date. The amount of match (cash or "in-kind services") used to date for the project. -- Match Balance Remaining. Subtract Match to Date from Match Required. Signatures / Certification The Provider must date and sign the invoice certification. Submitting the Invoice to DEP Provider must submit an original invoice with the signature.not a copy. Provider submits the original Invoice to the DEP staff person assigned as Agreement Administrator for the project. Payment The DEP Agreement Administrator will inform the Grantee whether the invoice is accepted or not accepted within 4 days of receipt. An Invoice will be accepted if DEP finds the Grantee has exhibited adequate compliance and performance according to terms of the Grant Agreement, and the invoice is completed according to instructions. The Agreement Administrator will sign / date the invoice indicating acceptance; retain one copy for the project file; and forward the original invoice to the NPS Program Manager in Augusta. The Provider can anticipate receipt of the payment from the State within 4 weeks of acceptance. DEP will retain 10% of the grant funds until closeout of the grant agreement.     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