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{"sheet":"Cover Form Mod (Prog Mgmt)","index":0,"n_rows":69,"n_cols":11,"rows_kept":69,"cut":false,"hidden":false,"merged":[[14,3,14,5],[14,6,14,8],[11,3,11,5],[12,3,12,5],[12,6,12,8],[13,3,13,5],[13,6,13,8],[74,2,74,5],[66,2,66,5],[68,1,68,5],[19,2,19,5],[41,2,41,5],[30,2,31,7],[42,2,43,6],[50,2,51,5],[37,2,38,4],[25,2,26,5],[72,2,72,5],[18,9,18,10],[63,1,63,9],[50,8,51,8],[50,9,51,9],[32,8,32,9],[33,8,33,9],[34,8,34,9],[35,8,35,9],[42,8,43,8],[42,9,43,9],[37,5,38,9],[15,3,15,5],[30,8,31,8],[30,9,31,9],[40,2,40,4],[18,2,18,3],[15,6,15,8],[16,3,16,5],[25,8,26,8],[25,9,26,9],[2,1,2,10],[4,1,4,11],[7,6,7,8],[8,6,8,8],[9,6,9,8],[8,3,8,5],[9,3,9,5],[7,3,7,5],[5,4,5,10],[5,1,5,3],[10,6,10,8],[10,3,10,5],[11,6,11,8]]}
[]
[null,null,null,null,null,null,null,null,null,null,"Doc: March 2021"]
[null," INVOICE SUBMITTAL CHECKLIST"]
[]
[]
[null,"PROJECT NAME:"]
[]
[null,null,null,"DATE (MM/DD/YYYY):",null,null,"0/00/00"]
[null,null,null,"INVOICE SUMMARY NO.:"]
[null,null,null,"FPID NO.:"]
[null,null,null,"CONTRACT NO.:"]
[null,null,null,"CONTRACT EXPIRES ON (MM/DD/YYY):"]
[null,null,null,"AGENCY:"]
[null,null,null,"AGENCY STREET ADDRESS:"]
[null,null,null,"AGENCY CITY, STATE, ZIP:"]
[null,null,null,"VENDOR ID:"]
[null,null,null,"DOT COORDINATOR:"]
[]
[null,null,"Type of Agreement:",null,"LAP","CIGP","SCOP","TRIP","   OTHER\n    Explain:"]
[]
[null,null,"REQUIRED DOCUMENTS"]
[null,null,"DFS Summary",null,null,null,null,null,"   Yes","No"]
[null,null,"Cost Summary",null,null,null,null,null,"   Yes","No"]
[null,null,"Project Monitoring Status Report",null,null,null,null,null,"   Yes","No"]
[null,null,"Schedule of Values",null,null,null,null,null,"   Yes","No"]
[null,null,"Certification Disbursement of \nPrevious Periodic Payment to Subcontractors",null,null,null,null,null,"   Yes","No"]
[]
[null,null,"Certifications of Compliance with Plans & Specifications",null,null,null,null,null,"   Yes","No"]
[]
[null,null,"SUPPLEMENTAL AGREEMENTS & RETAINAGE"]
[null,null,"Has Contract Been Amended (Time Extension, Increase/Decrease in Funding, etc.?) ",null,null,null,null,null,"   Yes","No"]
[]
[null,null,"Date of last Contract Amendment (MM/DD/YYYY)"]
[null,null,"Original Contract Amount ($)"]
[null,null,"Modified Contract Amount ($)"]
[null,null,"What percentage of retainage is being held (%)?"]
[null,null,"Has retainage been reduced from previous invoice?",null,null,null,null,null,"   Yes","No"]
[null,null,"If yes, please explain:"]
[]
[]
[null,null,"FINAL INVOICE?",null,null,null,null,null,"   Yes","No"]
[null,null,"If Yes, is the retainage being paid out?",null,null,null,null,null,"   Yes","No"]
[null,null,"Has Construction Close Out (Blue Folder) been submitted to FDOT?\nOps Center or CEI Oversight Consultant? ",null,null,null,null,null,"   Yes","No"]
[]
[]
[null,null,"FINAL INVOICES W/ CONSTRUCTION MUST ALSO SUBMIT"]
[null,null,"Final Release of Liens",null,null,null,null,null,"   Yes","No"]
[null,null,"Materials Certification Letter",null,null,null,null,null,"   Yes","No"]
[null,null,"Contract Affidavit & Surety Consent (700-050-21)",null,null,null,null,null,"   Yes","No"]
[null,null,"Final Inspection Acceptance (500-010-40)",null,null,null,null,null,"   Yes","No"]
[null,null,"Record of Final Plans & Documentation \n(525-010-40)",null,null,null,null,null,"   Yes","No"]
[]
[null,null,"Certifications of Compliance with Plans & Specifications",null,null,null,null,null,"   Yes","No"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"I certify, under penalties of perjury, that the Agency has complied with the provisions of this Agreement:"]
[]
[]
[null,"Signed:",null,null,null,null,null,"Date:",{"$f":"G8","v":"0/00/00"}]
[]
[null,", Local Agency Project Manager"]

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["Agency:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G13","v":0},null,null,"Doc: March 2021","Invoice No.:",null,{"$f":"'Cover Form Mod (Prog Mgmt)'!G9","v":0}]
["Agency Address:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G14","v":0},null,null,null,"Invoice Period:",null,"0/00/00 -  0/00/00"]
["Agency City, State, Zip Code:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G15","v":0}]
["Vendor ID:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G16","v":0},null,null,null,"Total Invoice Amount ",null,{"$f":"C36","v":0}]
[null,null,null,null,null,"Total Invoice Amount FDOT Participating: ",null,{"$f":"F36","v":0}]
["Bill To:"]
["Florida Department of Transportation - District 4","3400 West Commercial Boulevard",null,null,null,"FDOT Contract/Agreement No.",null,{"$f":"'Cover Form Mod (Prog Mgmt)'!G11","v":0}]
["Main: (866) 336-8435","Fort Lauderdale, Florida 33309-3421",null,null,null,"FDOT Participation Total ($)",null,{"$f":"B36","v":0}]
[null,null,null,null,null,"FDOT Participation Amount (%)",null,1]
[null,null,null,null,null,"FDOT Contract Remaining Balance:",null,{"$f":"H36","v":0}]
[]
[null,null,"FILL IN APPLICABLE YELLOW CELLS"]
["Project Name:",{"$f":"'Cover Form Mod (Prog Mgmt)'!E6","v":0}]
["Contract Number:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G11","v":0}]
[]
["Project Phase(s)                                     \nSelect from drop down menu. Must match Exhibit B of Agreement.","FDOT\nMAX Participation Amount by Phase","TOTAL\nInvoice Amount \nby Phase","FDOT \nNon-Participating Amount by Phase ","FDOT\nParticipating Amount by Phase ","Invoice Amount \nfor\nFDOT Reimbursement","Total FDOT Previous Payments","Remaining Balance by Phase","Needed for Formula (DO NOT DISPLAY in PRINT)"]
["Phase 34/38: Preliminary Engineering",0,0,0,0,0,0,0,0]
["Phase 54/58: Construction",0,0,0,0,0,0,{"$f":"IF(E18=\"\",\"\",B18-F18-G18)","v":0},{"$f":"B18-G18","v":0}]
["Phase 64/68: Construction, Engineering and Inspection",0,0,0,{"$f":"C19-D19","v":0},{"$f":"IF(E19=\"\",\"\",IF($H$9*E19>I19,I19,(E19*$H$9)))","v":0},0,{"$f":"IF(E19=\"\",\"\",B19-F19-G19)","v":0},{"$f":"B19-G19","v":0}]
[null,null,null,null,null,{"$f":"IF(C20=\"\",\"\",IF($H$9*C20>I20,I20,(C20*$H$9)))","v":""},null,{"$f":"IF(C20=\"\",\"\",B20-F20-G20)","v":""},0]
["Capital Equipment ",null,null,null,null,"",null,"",0]
["In-house Costs*:",null,null,null,null,"",null,"",0]
["Salaries",null,null,null,null,"",null,"",0]
["Fringe Benefits",null,null,null,null,"",null,"",0]
["Contractual Services",null,null,null,null,"",null,"",0]
["Other Direct Costs",null,null,null,null,"",null,"",0]
["a.      ",null,null,null,null,"",null,"",0]
["b.     ",null,null,null,null,"",null,"",0]
["c.      ",null,null,null,null,"",null,"",0]
["d.     ",null,null,null,null,"",null,"",0]
["e.      ",null,null,null,null,"",null,"",0]
["f.      ",null,null,null,null,"",null,"",0]
[null,null,null,null,null,"",null,"",0]
[null,null,null,null,null,"",null,"",0]
[null,null,null,null,null,"",null,"",0]
["Totals:",{"$f":"SUM(B17:B35)","v":0},{"$f":"SUM(C17:C35)","v":0},0,0,0,0,{"$f":"SUM(H17:H35)","v":0}]
["*Must be pre-approved by FDOT prior to executing the Grant Agreement."]
[]
[]
["Request for Payment Certification as Required by 2 CFR 200.415:"]
["By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award (ONLY applicable to Federal-Aid assisted contracts). I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. \n(U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)"]
[]
[]
[]
[]
[]
[" Authorized Official Signature:",null,null,null,null,"Date:"]
[]
["Printed Name:"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["Phase 14/18: Planning"]
["Phase 34/38: Preliminary Engineering"]
["Phase 44/48: Right of Way Acquisition"]
["Phase 54/58: Construction"]
["Phase 64/68: Construction, Engineering and Inspection"]

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["Agency:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G13","v":0},null,null,"Doc: March 2021","Invoice No.:",null,{"$f":"'DFS (Variable-Participation)'!H1","v":0}]
["Agency Address:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G14","v":0},null,null,null,"Invoice Period:",null,{"$f":"'DFS (Variable-Participation)'!H2","v":"0/00/00 -  0/00/00"}]
["Agency City, State, Zip Code:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G15","v":0},null,null,null,"Total Invoice Amount ",null,{"$f":"'DFS (Variable-Participation)'!H4","v":0}]
["Vendor ID:",{"$f":"'Cover Form Mod (Prog Mgmt)'!G16","v":0},null,null,null,"Total Invoice Amount FDOT Participating: ",null,{"$f":"'DFS (Variable-Participation)'!H5","v":0}]
[]
["Bill To:"]
["Florida Department of Transportation - District 4","3400 West Commercial Boulevard",null,null,null,"FDOT Contract/Agreement No.",null,{"$f":"'DFS (Variable-Participation)'!H7","v":0}]
["Main: (866) 336-8435","Fort Lauderdale, Florida 33309-3421",null,null,null,"FDOT Participation Total ($)",null,{"$f":"'DFS (Variable-Participation)'!H8","v":0}]
[null,null,null,null,null,"FDOT Participation Amount (%)",null,{"$f":"'DFS (Variable-Participation)'!H9","v":1}]
[null,null,null,null,null,"FDOT Contract Remaining Balance:",null,{"$f":"'DFS (Variable-Participation)'!H10","v":0}]
[]
[]
[{"$f":"'DFS (Variable-Participation)'!A13","v":"Project Name:"},{"$f":"'Cover Form Mod (Prog Mgmt)'!E6","v":0}]
[{"$f":"'DFS (Variable-Participation)'!A14","v":"Contract Number:"},{"$f":"'Cover Form Mod (Prog Mgmt)'!G11","v":0}]
[]
["COST SUMMARY"]
[]
["VENDOR","INVOICE DATE","INVOICE #","VENDOR AMOUNT","GRANT PARTICIPATING AMOUNT","GRANT NON-PARTICIPATING AMOUNT","CHECK #","PAYMENT DATE"]
[null,null,null,0,0,{"$f":"D19-E19","v":0}]
[null,null,null,0,0,{"$f":"D20-E20","v":0}]
[null,null,null,0,0,0]
[null,null,null,0,0,0]
[null,null,null,0,0,0]
[null,null,null,0,0,0]
[null,null,"Total:",{"$f":"SUM(D19:D24)","v":0},{"$f":"SUM(E19:E24)","v":0},0," "]