ATTACHMENT D REQUEST FOR PAYMENT FORM.PDF

SWG WEATHERIZATION Attachment D
ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT SUMMARY SHEET PAGE 1 OF 2
Recipient Maricopa County Date
Contract No 203-18 Contract Period: from 7/1/2017 to 12/31/2017 Pay Req. No/Mo
Activity Weatherization Assistance Program Direct Wire Dep Yes No
Recipient Address 234 N. Central Ave., 3rd Floor City Phoenix
Contact Person Yvonne Seel ZIP 85004
Phone 602-506-4842 Email yseel@mail.maricopa.gov Fax 602-372-2292
Program Specialist Trisha Ekenberg Email trisha.ekenberg@azhousing.gov County Maricopa
Itemized Payment Statement (Sheet 2 of 2) must accompany this form. Include copies of invoices, cashed checks, and other backup
documentation. SIGNATURES are required for processing.
a b c d d e f g h
Budget Line Item or ASAP SWG Source Source Total Amount Balance in Amount of this New
Activity No. No. FY2017 Program Year Program Year Req. to Date Account Request Balance
1. DOE Administration $ - $ -
2. DOE Training & TA $ - $ -
3. DOE Program Ops $ - $ -
4. DOE Health & Safety $ - $ -
5. DOE Financial Audit $ - $ -
6. DOE Liability Ins $ - $ -
7. DOE Total Draw 0.00
8. LIHEAP Admin. N/A $ - $ -
9. LIHEAP Training/TA N/A $ - $ -
10. LIHEAP Program OpsN/A $ - $ -
11. LIHEAP Total Draw N/A 0.00
12. SWG Admin. N/A $ 3,450.00 $ 266.50 $ 3,183.50 $ 3,183.50
13. SWG Program Ops. N/A $ 26,451.00 $ 1,950.00 $ 24,501.00 $ 24,501.00
14. SWG Health/Safety N/A $ 8,433.00 $ 715.00 $ 7,718.00 $ 7,718.00
15. SWG Total Draw N/A 0.00
Total $ 38,334.00 $ - $ - $ 2,931.50 $ 35,402.50 $ - $ 35,402.50
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 Appr Date
REV. 1-2014

F-4
ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT -ITEMIZED PAYMENT STATEMENT PAGE 2 OF 2
Recipient Maricopa County Date
Contract No 203-18 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