Extracted text (via pymupdf_layout)
3082 characters
Anticipated Collections Addendum from Non-Federal Sources Please provide the information requested in the table below. This information will be used to complete your Memorandum of Agreement (MOA). See Page 2 for additional instructions and an explanation of terms. 1. Agency Information Agency Name: Maricopa County Recorder Tax Identification Number (TIN): 866000472 Data Universal Numbering System (DUNS) or 077535144 Business Partner Network (BPN) Number: 2. Billing (Accounts Payable) Point of Contact (POC) Information Name: Joey Rodenback Phone Number (xxx-xxx-xxxx): 602-506-2268 Fax Number (xxx-xxx-xxxx): 602-506-3069 E-mail Address: jrodenback@risc.maricopa.gov Address: 111 South 3rd Avenue Address (2nd line): Suite 102 City, State, Zip Code: Phoenix, Arizona 85003 3. Customer Payment and Budgeting Information Purchase Commitment Number: N/A Payment Method: Credit Card Amount Obligated (Budgeted): $650.00 Funds Expiration Date: 06/30/2019 4. Program POC Name: Jasper Altaha Phone Number (xxx-xxx-xxxx): 602-506-2269 E-mail Address: jaltaha@risc.maricopa.gov This addendum will commence as soon as all signatures are obtained in accordance with the Memorandum of Agreement. Both parties must agree to any amendments prior to their implementation in accordance with the Memorandum of Agreement. [Insert Authorized Signatory Name] Jonathan M. Mills [Insert Position/Title] Acting Chief, SAVE Program, DHS USCIS Date Date Internal SAVE Use ONLY Agency High Level Identifier: 1 Rev. Ver. 6/2013 INSTRUCTIONS FOR COMPLETING THIS ADDENDUM 1. Type or legibly print the information requested. See below for an Explanation of Terms. 2. Have your agency’s authorized signatory sign and date the Addendum. 3. Return the Addendum to your SAVE Program Agency Manager via e-mail, or fax (802) 860-6907 or U.S. mail to: SAVE Program U.S. Citizenship and Immigration Services Department of Homeland Security 10 Fountain Plaza Buffalo, NY 14202 If you require an original signature from the SAVE Program Chief on your copy of this Addendum, please mail your signed Addendum to: SAVE Program U.S. Citizenship and Immigration Services MS2620 Department of Homeland Security Washington, DC 20529-2620 **Do not send any payment along with this ACA; you will receive a monthly bill for any use. EXPLANATION OF TERMS 1DUNS or BPN Number: This field may be left blank if your agency does not have a DUNS or BPN number. 2Purchase Commitment Number: This field may be left blank if your agency does not use this number or a similar identifier. 3Amount Obligated (Budgeted): This amount may be an estimate, though SAVE recommends a minimum of $300 per year (calendar or fiscal), which is equal to $25 per month and is the minimum amount your agency can be invoiced in a single month (unless you do not submit a single query). 4Funds Expiration Date: This date is the time at which your agency’s obligated funding amount runs out. This may be the end of the SAVE Program fiscal year (for example, September 2011), the end of your fiscal year, or the end of the calendar year. 2 Rev. Ver. 6/2013