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Maricopa County Human Services Department Community Services Division Financial Assistance Claim Form FY18 Subcontractor: Month & Year Contract # Address: PQ# Purchase Order # City/State/Zip: Check Fee PO# Contact Person: Contract Dates Phone Number: Date Submitted Fax Number: Number of Checks: E-mail Address: Rate per Check: Line Item Expenditures B. Amount D. New Total A.Contract Budget Requested YTD C. Amount of this E. New Balance in Budget Requested YTD Fund Name Amount (from D. previous Request Budget (A-D) Code (B+C) claim) Signature certifies that all activities performed with contracted funds have been carried out in accordance with the contract to the best of the signer's knowledge. Authorization Signature Title Date Payment Requirements: An authorized signature is required. After signature, please scan and EMAIL this form . An incomplete or incorrect payment request will be returned for correction and may delay payment. This claim must be received by Maricopa County Human Services Department by the 10th working day of each month. Completed forms will be emailed to Lilian Perez at PerezL008@mail.maricopa.gov . MCHSD/CSD USE ONLY Administrative Services Supervisor Approval Date Program Accountant Date Jun-17