ADOH AMENDMENT NO. 002 D-REQUEST FOR PAYMENT PAGE 2.PDF

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ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT -ITEMIZED PAYMENT STATEMENT PAGE 2 OF 2
Recipient Maricopa County Date
Contract No 222-18 Pay Req. No
Budget Line item Description of Paid (or Payable) to Date Check # Invoice Balance Name of other
(DOE, LIHEAP, SWG) Expense (List in Paid Invoice Amount paid by source
& according to PO Charged to other
Job No funding source) DOE/SWG/LIHEAP source
Totals