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4/3/23, 2:11 PM MPO List - FY23 - 959 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=959&Web=b61612d1-e2fa-43e0-b368-9e5ef5495991 1/3 SharePoint Main MPO Docs Purchase Order # Change Order Current Encumbrance Original MPO # Requester Name Location Scope Bureau Contract No. Supplier Name Supplier ID (APP#) or Vendor ID (AFIS #) Supplier E-mail Manual Purchase Orders MPO List STATE OF ARIZONA Arizona Department of Health Services Procurement Office 150 N 18th Avenue, Suite 530 Phoenix, AZ 85007 Manual Purchase Order 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 FY23 - 959 Payment Terms NET 30 FOB Destination No Contract Information Letty Medina ADHS PREP BIDS S Bureau of Infectious Disease and Services (BIDS) BIDS (Bureau of Infectious Disease and Services) IGA2021-067 LAB-Maricopa IV0000002618 k.mason@maricopa.gov 4/3/23, 2:11 PM MPO List - FY23 - 959 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=959&Web=b61612d1-e2fa-43e0-b368-9e5ef5495991 2/3 Supplier Address Date Effective Date Termination Date Sub Total Tax Freight Total Encumbrance Distribution is attached Does this form contain Federal Funding? Maricopa County Public Health 4041 N Central Avenue STE 1400 Phoenix, AZ 85012 4/3/2023 1/1/2023 12/31/2023 Line Items Extended Price is calculated by multiplying Quantity by Unit Price. Line Quantity Unit Description Unit Price (#) Extended Price ($) Totals ($) 1 1 EA CHLAMYDIA & GONORRHEA COMBINATION TESTING $12.30 $12,410.70 $12,410.70 2 3 4 $12,410.70 5 Calculate Total 6 7 8 9 10 Encumbrance Distribution No Yes Line BFY Function Dept. Obj Unit PPC Amount (#) CFDA# 1 2023 FEDEDC2287 6811 5129 1223 $12,410.70 93.977 4/3/23, 2:11 PM MPO List - FY23 - 959 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=959&Web=b61612d1-e2fa-43e0-b368-9e5ef5495991 3/3 Encumbrance Total ($) GAE # All PDS signed? 2 3 4 5 6 $12,410.70 230000002742 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://www.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. For Maricopa County _________________________________________ Chairman, Board of Supervisors Date ATTEST: ________________________________________ Clerk of the Board Date APPROVED AS TO FORM: ________________________________________ Maricopa County Attorney Date