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CONTRACT NO: C-86-16-071-3-04
AMENDMENT TO
IGA CONTRACT
Between
MARICOPA COUNTY
By and Through
DEPARTMENT OF PUBLIC HEALTH
and
ARIZONA DEPARTMENT OF HEALTH SERVICES
I. Approve an additional $836.40 to the IGA ADHS16-116340 between Maricopa
County, Department of Public Health and Arizona Department of Health Services for
STD laboratory testing. The budget period is January 1, 2017 through December 31,
2017. The Contract term is January 1, 2016 through December 31, 2020. The
contract amount for this budget period is increased to $12,841.20.
II. All other terms and conditions of the original contract and other amendments remain
in full force and effect.
IN WITNESS WHEREOF, the parties agree to the changes indicated herein:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By:
Steve Chucri, Chairman, Board of
Supervisors
Date
ATTEST
Clerk of the Board
Date
APPROVED AS TO FORM
Attorney for Maricopa County
Date
Page 1
STATE OF ARIZONA REMITTANCE ADVICE WARRANTINO
218479900
AGY: HSA AGENCY CONTACT: NSA ACCOUNTS PAYABLE 802-542-8354
INVOICE NO. INVOICE DI. INVOICE DESCRIPTION • DOCUMENT/LINE NO, INVOICE AMT. DISCOUNT AMT. NETAMT,
JAN 17 10/0312017 ADHS143-11634011GA - STD PROGRAM pprpii HSA, PR0000655358 / 1 $836.40 , $0.00 Q364O
P0268052 f)32. % -7 - '1--2. -)( -5 TINA-6- 'CA 61
JUL 17 10/03/2017 ADHS10-116340 I IGA - STD PROGRAM PRCP21, NSA, PR0000655366 / 1 $1,156 20 $0.00 .80-
P0268052 -3 7— ' .{,0 21 -$T--;-'.4 --;-raii,e.) c y i 7 1 12,-.0 _..„
JUN 17 .13/2017 ADHS16-110340 I IGA - STD PROGRAM PRCPZ1, FISA, PR0000055307 / 1 BM 0840 $0.00 -. .
P0269052 6,3 2,--- Sie2--1 -.S1-6-• X Sffb4A-413 C.:y
MAR i 7 1010312017 ADHS16-116340 J IGA - STD PROGRAM , PRcv.21.-1A, P110000885381 /1 , VA80.30 $0,00
P0269052 63 2- pi0.7 - SreY --f .t.-DCA-1' cy t ---? . i Lf
MAY 17 • 10/0312017 A H 16-116340 I IGA - STD PROGRAM PRO 21, FISA, P80000055411 / 1 $1,131.60 $0.00 Wel/
P0269052 I:773 2- (R.P.-7 -5-a--,- -.5-r-Q046 _k i --7 . 1)31Aeb
.
. .
• •
. .
! • .
IF REMITTANCE ADVICE ABOVE IS BLANK SEE HTTP1/WWWVENPAY.GAO.AZDOA.GOV/ FOR FURTHER DETAIL' S,
EVER WONDER WHERE YOUR PAYMENT FROM THE STATE IS? OR WHICH •
STATE AGENCY PAID YOU THROUGH DIRECT DEPOSIT/ACH? VISIT OUR
VENDOR PAYMENT wEBsITE, HTTP ://WWW.vENPAY.GAD.AZODA.GOV/.
VENDOR NAME: IVIARICOPA COUNTY ISSUE DATE: WARRANT AMOUNT:
VENDOR ID: PZ000010983 10/05/2017 $5,781.00
Alu OT d-doDoe 01-113
ID [JAITE — 8flo 1221
mtTSSUED VOID AFTER-i5 BANK WARRANT NO
MO-DAY-YRI:., 21 8470900
10/05/2017 IL:211i;
0,1EPARTMENT DOCUMENT 114
•.• NSA
• 190000138215 PAY THIS AMOUNT
$5.-:781-10
• *4-k-.44,64,A4-**k.k1;4),.k101.1.*to',W1,...0 ..**,0'..Yx....4..14.?.;;.:i . , ***FIVE THOUSAND SEVEN HUNDRED :Rig !. NE Alb 00/100 DOLLARS
4113ZARTMENT OF ADMINISTRATION
•• •••?.;:;m:'•:?;".•I•• ,:ii 0.'
V,Va COUNTERSIGNED , GOVERNOR
y,04,3TH •VTAIQ'AR:41NO RANK OF STATE TREASURER OFARIZONA
B931099000 L 2 2 LO L 31: 0000000000 Lo