Payment Request

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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: