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HTF Eviction Prevention- Maricopa County Attachment D- Page 35 ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT SUMMARY SHEET PAGE 1 OF 2 Recipient Maricopa County Date Contract No 523-19 Contract Period: from 02/01/2019-04/30/2020 Pay Req. No/Mo Activity HTF Administration, Support Services, Prevention Assistance Direct Wire Dep Yes X No Recipient Address 234 N. Central Ave. Suite 3000 City Phoenix Contact Person Sandra Mendez ZIP 85004 Phone 602-506-2316 Email Sandra.Mendez@Maricopa.gov Fax Program Specialist Ryan Vernick Email Ryan.Vernick@azhousing.gov County Maricopa Itemized Payment Statement (Sheet 2 of 2) must accompany this form. Include copies of timesheets and other backup documentation. ORIGINAL SIGNATURES are required for processing. a b c d e f g h Budget Line Item or IDIS HTF HUD-COC Total Amount Balance in Amount of this New Activity No. Act No. 2019 Req. to Date Account Request Balance Act. 1 Administration $17,553.00 $17,553.00 $ 17,553.00 Act. 2 Support Services $86,297.00 $86,297.00 $ 86,297.00 Act. 3 Prevention Assist. $360,400.00 $360,400.00 $ 360,400.00 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - Total $ 464,250.00 $ - $ - $ 464,250.00 $ - $ 464,250.00 Recipient Authorized Signature Date Title Recipient Authorized Signatory certifies that all activities undertaken by the contractor with funds provided under this contract have been carried out in accordance with the contract. Attach wiring information if not previously submitted. Attach alternate mailing address if necessary. Performance Reports Current Not Current For ADOH Use Only ADOH Program Specialist Approval Date ADOH Program Administrator ApprovalDate HTF Eviction Prevention-Maricopa County ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT -ITEMIZED PAYMENT STATEMENT PAGE 2 OF 2 Recipient Date Contract No 523-18 Contract Period: from 2/1/2019 to 4/30/2020 Pay Req. No Budget Line Description of Paid (or Payable) to Date Check # Invoice Balance Name of other Item or Expense (List in Paid Invoice Amount paid by source Activity No according to PO Charged to other funding source) COC/HTF source Totals