EXHIBIT H - REIMBURSEMENT REQUEST AND INVOICE.PDF

Exhibit H: Milestone Reimbursement Request and
Invoice Forms
H.1 MILESTONE REIMBURSEMENT REQUEST FORMS

[Organization Name]
[Street Address Line 1]
[Street Address Line 2]
[City, State ZIP Code]
Reimbursement Request Form
Milestone #1
Report Prepared For:
Maricopa County
Air Quality Department
Division of Planning & Analysis
CFI Funded EV Infrastructure Program
Milestone Start Date: Milestone End Date:
Federal Award Identification Number: 693JJ32540008
Project Title:
Project Manager:
Instructions for Submitting a Reimbursement Request
To request reimbursement, you must complete and submit the required documentation
outlined below. Incomplete submissions will be returned for revision and may delay
processing.
Required Documents for Submission
Your reimbursement request must include the following:
1. Completed Reimbursement Checklist
Fill out all required fields in the checklist.
Ensure the checklist accurately reflects all items for which reimbursement is requested.
2. Completed Invoice Template
Include your organization's name, address, and invoice number.
Provide a detailed breakdown of requested reimbursement amounts and corresponding line
items.
3. Copies of Supporting Documentation
Provide legible copies of all documents listed on the checklist.
Ensure each document clearly corresponds to an item on the checklist.

Submission Instructions
1. Combine all required documents into a single PDF file, if submitting electronically.
Verify that:
- The checklist and invoice are fully completed.
- All required supporting documentation is attached.
2. Submit the completed reimbursement request via:
Email to:
- Milly Chandler at Milly.Chandler@Maricopa.gov; and
- Michael Joslin at Michael.Joslin@Maricopa.gov; and
- Maricopa County CFI Funded EV Infrastructure Program at EVChargers@Maricopa.gov; and
- MCAQD Grants at AQDGrants@Maricopa.Gov
Preliminary Design and NEPA Review Documentation Checklist
RFP process documentation (Process, number of bids received, awardee information,
Preliminary designs (must include architectural and engineering designs)
Invoice from contractor for preliminary design
Quote from contractor for final design, equipment cost, installation and construction
fees
National Environmental Policy Act (NEPA) categorical exclusion checklist or full review
Cost share documentation
Invoice reimbursement request template, filled out

[Organization Name]
[Street Address Line 1]
[Street Address Line 2]
[City, State ZIP Code]
Reimbursement Request Form
Milestone #2
Report Prepared For:
Maricopa County
Air Quality Department
Division of Planning & Analysis
CFI Funded EV Infrastructure Program
Milestone Start Date: Milestone End Date:
Federal Award Identification Number: 693JJ32540008
Project Title:
Project Manager:
Instructions for Submitting a Reimbursement Request
To request reimbursement, you must complete and submit the required documentation
outlined below. Incomplete submissions will be returned for revision and may delay
processing.
Required Documents for Submission
Your reimbursement request must include the following:
1. Completed Reimbursement Checklist
Fill out all required fields in the checklist.
Ensure the checklist accurately reflects all items for which reimbursement is requested.
2. Completed Invoice Template
Include your organization's name, address, and invoice number.
Provide a detailed breakdown of requested reimbursement amounts and corresponding line
items.
3. Copies of Supporting Documentation
Provide legible copies of all documents listed on the checklist.
Ensure each document clearly corresponds to an item on the checklist.

Submission Instructions
1. Combine all required documents into a single PDF file, if submitting electronically.
Verify that:
- The checklist and invoice are fully completed.
- All required supporting documentation is attached.
2. Submit the completed reimbursement request via:
Email to:
- Milly Chandler at Milly.Chandler@Maricopa.gov; and
- Michael Joslin at Michael.Joslin@Maricopa.gov; and
- Maricopa County CFI Funded EV Infrastructure Program at EVChargers@Maricopa.gov; and
- MCAQD Grants at AQDGrants@Maricopa.Gov
Equipment Procurement and Permits Issued Checklist
Copy of permits issued (construction, dust control permit, electrical, etc.)
Permit invoices
Equipment invoices: Equipment procured must be that listed in the quote from
contractor. If different, documentation of the reason must be included in this package
Quote from contractor for final design, equipment cost, installation and construction
fees
Cost share documentation
Invoice reimbursement request template, filled out

[Organization Name]
[Street Address Line 1]
[Street Address Line 2]
[City, State ZIP Code]
Reimbursement Request Form
Milestone #3
Report Prepared For:
Maricopa County
Air Quality Department
Division of Planning & Analysis
CFI Funded EV Infrastructure Program
Milestone Start Date: Milestone End Date:
Federal Award Identification Number: 693JJ32540008
Project Title:
Project Manager:
Instructions for Submitting a Reimbursement Request
To request reimbursement, you must complete and submit the required documentation
outlined below. Incomplete submissions will be returned for revision and may delay
processing.
Required Documents for Submission
Your reimbursement request must include the following:
1. Completed Reimbursement Checklist
Fill out all required fields in the checklist.
Ensure the checklist accurately reflects all items for which reimbursement is requested.
2. Completed Invoice Template
Include your organization's name, address, and invoice number.
Provide a detailed breakdown of requested reimbursement amounts and corresponding line
items.
3. Copies of Supporting Documentation
Provide legible copies of all documents listed on the checklist.
Ensure each document clearly corresponds to an item on the checklist.

Submission Instructions
1. Combine all required documents into a single PDF file, if submitting electronically.
Verify that:
- The checklist and invoice are fully completed.
- All required supporting documentation is attached.
2. Submit the completed reimbursement request via:
Email to:
- Milly Chandler at Milly.Chandler@Maricopa.gov; and
- Michael Joslin at Michael.Joslin@Maricopa.gov; and
- Maricopa County CFI Funded EV Infrastructure Program at EVChargers@Maricopa.gov; and
- MCAQD Grants at AQDGrants@Maricopa.Gov
Installation Completion Checklist
Full site design
Quote from contractor for final design, equipment cost, installation and construction
fees
Invoice from installation and construction
Final inspection results
Certificate of Completion
Images of completed Electric Vehicle Charging Stations (EVCS)
Cost share documentation
Invoice reimbursement request template, filled out

[Organization Name]
[Street Address Line 1]
[Street Address Line 2]
[City, State ZIP Code]
Reimbursement Request Form
Milestone #4
Report Prepared For:
Maricopa County
Air Quality Department
Division of Planning & Analysis
CFI Funded EV Infrastructure Program
Milestone Start Date: Milestone End Date:
Federal Award Identification Number: 693JJ32540008
Project Title:
Project Manager:
Instructions for Submitting a Reimbursement Request
To request reimbursement, you must complete and submit the required documentation
outlined below. Incomplete submissions will be returned for revision and may delay
processing.
Required Documents for Submission
Your reimbursement request must include the following:
1. Completed Reimbursement Checklist
Fill out all required fields in the checklist.
Ensure the checklist accurately reflects all items for which reimbursement is requested.
2. Completed Invoice Template
Include your organization's name, address, and invoice number.
Provide a detailed breakdown of requested reimbursement amounts and corresponding line
items.
3. Copies of Supporting Documentation
Provide legible copies of all documents listed on the checklist.
Ensure each document clearly corresponds to an item on the checklist.

Submission Instructions
1. Combine all required documents into a single PDF file, if submitting electronically.
Verify that:
- The checklist and invoice are fully completed.
- All required supporting documentation is attached.
2. Submit the completed reimbursement request via:
Email to:
- Milly Chandler at Milly.Chandler@Maricopa.gov; and
- Michael Joslin at Michael.Joslin@Maricopa.gov; and
- Maricopa County CFI Funded EV Infrastructure Program at EVChargers@Maricopa.gov; and
- MCAQD Grants at AQDGrants@Maricopa.Gov
Operational Launch Checklist
MCAQD site visit final report
Press release details for operational launch
Exhibit F.2: Final Project Data Report
Exhibit F.3: Charging station profile, contact information for person responsible for
data submission, and port information
One Time data submittals for station operator identity, distributed energy resource
information, and capital and installation cost data to EV-ChART, referenced in Exhibit
F.4
Cost share documentation
Invoice reimbursement request template, filled out

H.2 INVOICE FORM

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