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STATE OF ARIZONA Arizona Department of Health Services Procurement Office Manual Purchase Order 150 N 18th Avenue, Suite 530 Phoenix, AZ 85007 Payment Terms NET 30 Change Order Contract Information Purchase Order # FY23 - 897 No Current Encumbrance BILL TO: (send invoices to invoices@azdhs.gov) SHIP TO Arizona Department of Health Services Accounts Payable 150 N 18th Ave, Suite 260 Phoenix, AZ 85007 FOB Destinatior Original MPO # Requester Name Location Scope Bureau Contract No. Supplier Name Supplier ID (APP#) or Vendor ID (AFIS #) Supplier E-mail Supplier Address Date Effective Date Termination Date Christine Wampler ADHS PREP EDC S HIV Prevention ABRC IGA2021-051 MARICOPA COUNTY 1v0000002618 K.MASON@MARICOPA.GOV MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH 4041 N CENTRAL AVE PHOENIX AZ 85012 12/7/2022 8/1/2022 7/31/2023 Line Items Extended Price is calculated by multiplying Quantity by Unit Price. Line Quantity Unit Description Unit Price (#) Extended Price ($) Totals ($) 1 1 YR HEPATITIS C $223,664.00 $223,664.00 Sub Total $223,664.00 TESTING & PATIENT NAVIGATION IGA2021-051 2 $0.00 Tax 3 $0.00 Freight 4 $0.00 Total $223,664.00 5 $0.00 Calculate Total 6 $0.00 7 $0.00 8 $0.00 9 $0.00 10 $0.00 Encumbrance Distribution No Does this form contain No Encumbrance Distribution is attached Federal Funding? Line BFY Function Dept. Obj Unit PPC Amount (#) CFDA# 1 2023 FEDEDC8168 6811 5135 0723 $223,664.00 93.940 2 3 6 Encumbrance Total ($) $223,664.00 GAE # 23*1911 All PDS signed? No Any off-contract MPOs over $10k require Procurement Disclosure Statements (PDS) be attached CFDA Information: Contractor shall comply with the requirements of OMB Circular. For grant restrictions, refer to https:/Awww.ecfr.gov/cgi-bin/text-idx?tpl=/ecfrbrowse/Title02/2cfr200_main_02.tpl Federal Funding Accountability and Transparency Act If applicable, the Contractor/Grantee shall submit to ADHS via email the Grant Reporting Certification Form. This form and the instructions can be downloaded below and must be returned to the ADHS by the 15th of the month following that in which the award was received. The form shall be completed electronically, and submitted using the steps outlined in the Grant Reporting Certification Form Instructions and emailed to us. All required fields must be filled including Top Employee Compensation, if applicable. Completing the Grant Reporting Certification Form is required for compliance with the Office of Management and Budget (OMB). Failure to timely submit the Grant Reporting Certification Form could result in the loss of funds. This requirement applies to all subcontractors/sub-awardees utilized by the Contractor/Grantee for amounts exceeding $30,000.00 during the term of the Award.