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Payment Request Form <br />State of California - Natural Resources Agency <br />DEPARTMENT OF PARKS AND RECREATION <br />PAYMENT REQUEST <br />State Grant Programs <br />See Instructions on Page 2. <br />t_ PROJECTNt1MBER 2_ CONTRACT NUMBER <br />3_ APPLICANT <br />4. PROJECT NAME <br />5. TYPE OF PAYMENT <br />1_I Advance 1 .1 Reimbursement ❑ Final <br />6. PAYMENT INFORMATION <br />Round ali figures m the irearesr dollar <br />a. Grant Project Amount $ <br />b. Funds Received To Date $ <br />c_ Available (a_ minus b_j $ <br />d. Amount Of This Request $ <br />e. Remaining Funds After This Payment (e. minus d.) $ <br />i. SEND WARRANT TO: <br />AGENCY NAME <br />STREET ADDRESS <br />CFYISTATEIZIP CODE <br />8. CERTIFICATION AND SIGNATURE OF PERSON AUTHORIZED IN RESOLUTION <br />l represent and warrant that l have Full authority to execute this payment request on behalf of the Grantee. l declare <br />under penalty of perjury. under the laws of the State of California, that this report. and any accompanying documents, for <br />the above -mentioned Grant is true and correct to the best of my knowledge. <br />S3GNATtJRE OF PERSON AUTHORIZE ❑ 1N RES O L UT IC•N TITLE C A T <br />FOR CALIFORNIA DEPARTMENT OF PARKS AND RECREATION USE ONLY <br />PAYMENT APPROVAL SIGNATURE DATE <br />DFR 212 (Rev. 3121315XExcel?d°. M15)(Page 1 of 2) <br />35 <br />