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Page 1 of 3 ARIZONA STATE CONTRACT CONTRACT RELEASE ProcureAZ Purchase Order No.: ADHS14-074958:3 Organizational Reference No.: PO0000129550 C-86-15-021-3-06 Issued: 07/13/2016 V Vendor Number: 000010983 Arizona Department of Health Services E Maricopa County Public Health S Bureau of Women and Children's Health N 4041 N. Central Avenue, #1400 H 150 N. 18th Avenue, Suite 320 Phoenix, AZ 85012 I Phoenix, AZ 85007 D US O P Email: procure@azdhs.gov R T O Contract No.: ADHS14-074958 (602) 364-1400 Title: HRPP Community Nursing MAIL INVOICE IN DUPLICATE TO: B Arizona Department of Health Services I Bureau of Women and Children's Health 150 N. 18th Avenue, Suite 320 L Phoenix, AZ 85007 L US Email: procure@azdhs.gov T O (602) 364-1400 Release Instructions TERMS AND CONDITIONS set forth in our Bid, Quotation, or Purchase Order are incorporated herein by reference and become a part of this order. Account Code: 2017--GENCFH0296--4341--1000--HS43010-6841--6841-PHS-WCH-------- Payment Terms: Net 30 ----HSA Shipping Terms: N/A Delivery Calendar Day(s) A.R.O.: 0 Item Description Requisition Quantity Unit Unit Price Total Class-Item 948-64 PO EFFECTIVE 7/1/16 - 6/30/17 *** CONTRACT EFFECTIVE 7/1/14 - 1 6/30/17 *** STATE FUNDING *** THIS LINE TO PAY FROM GENCFH0296/ 1.00 QTR $ 92,925.00 $ 92,925.00 2017 *** CONTRACTOR TO INVOICE ACCORDING TO CONTRACT PRICE SHEET *** THIS CONTRACT CONTAINS QUARTERLY ENCUMBRANCES *** TOTAL CONTRACT AMOUNT = $555,000.00 *********************HRPP/NICP COMMUNITY HEALTH NURSING SERVICES Class-Item 948-64 2 1.00 TOTAL $ 123,300.00 $ 123,300.00 THIS LINE TO PAY FROM FEDCFH1781 / 0917 *** FEDERAL FUNDING: MCH BLOCK GRANT CFDA 93.994 ***HRPP/NICP COMMUNITY HEALTH NURSING SERVICES Class-Item 948-64 3 1.00 TOTAL $ 60,000.00 $ 60,000.00 THIS LINE TO PAY FROM FEDCFH1787 / 0917 *** FEDERAL FUNDING: MCH BLOCK GRANT SPECIAL NEEDS CFDA 93.994 ***HRPP/NICP Page 2 of 3 ARIZONA STATE CONTRACT CONTRACT RELEASE COMMUNITY HEALTH NURSING SERVICES Class-Item 948-64 4 1.00 EA $ 100,925.00 $ 100,925.00 LINE TO ADD 2ND QTR FUNDING *** STATE FUNDING *** THIS LINE TO PAY FROM GENCFH0296/ 2017 *** QUARTERLY AMOUNT = $92,925.00 + ADDITIONAL AMOUNT OF $8,000.00 ********** HRPP/NICP COMMUNITY HEALTH NURSING SERVICES Class-Item 948-64 5 1.00 EA $ 92,925.00 $ 92,925.00 LINE TO ADD 3RD QTR FUNDING *** HRPP/NICP COMMUNITY HEALTH NURSING SERVICES Class-Item 948-64 6 1.00 EA $ 145,425.00 $ 145,425.00 LINE TO ADD ADDL DOLLARS AND 4TH QTR FUNDING ****** HRPP/NICP COMMUNITY HEALTH NURSING SERVICES TOTAL: $ 615,500.00 Approved By: Dee Vlahos Phone No.: (602) 364-1425 Page 3 of 3 ATTACHED TO AND A PART OF: Purchase Order ADHS14-074958:3 HRPP/NICP Community Nursing C-86-14-021-3-05 IN WITNESS WHEREOF, the parties agree to enter into this Agreement and its Amendments: FOR AND ON BEHALF OF MARICOPA COUNTY By_____________________________ Denny Barney, Chairman, Board of Supervisors _______________________________ Date ATTEST: _______________________________ Clerk of the Board _______________________________ Date APPROVED AS TO FORM: _______________________________ Attorney for Maricopa County _______________________________ Date 2