ATTACHMENT D REQUEST FOR PAYMENT FORM .PDF
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WEATHERIZATION REVISED Attachment D ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT SUMMARY SHEET PAGE 1 OF 2 Recipient Maricopa County Date Contract No 204-16 Contract Period: from 7/1/2016 to 6/30/2017 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. ORIGINAL SIGNATURES are required for processing. a b c d d e f g h Budget Line Item or ASAP DOE LIHEAP SWG Total Amount Balance in Amount of this New Activity No. No. FY16 FY16 FY17 Req. to Date Account Request Balance 1. DOE Administration $ 25,381.00 $ 25,381.00 $ 25,381.00 2. DOE Training & TA $ 17,850.00 $ 17,850.00 $ 17,850.00 3. DOE Program Ops $ 230,624.00 $ 230,624.00 $ 230,624.00 4. DOE Health & Safety $ 36,277.00 $ 36,277.00 $ 36,277.00 5. DOE Financial Audit $ - $ - $ - 6. DOE Liability Ins $ - $ - $ - 7. LIHEAP Admin. N/A $ 41,425.00 $ 41,425.00 $ 41,425.00 8. LIHEAP Training/TA N/A $ 7,336.00 $ 7,336.00 $ 7,336.00 9. LIHEAP Program Ops N/A $ 867,824.00 $ 867,824.00 $ 867,824.00 10. SWG Admin. N/A $ 11,509.00 $ 11,509.00 $ 11,509.00 11. SWG Program Ops. N/A $ 86,320.00 $ 86,320.00 $ 86,320.00 12. SWG Health/Safety N/A $ 28,774.00 $ 28,774.00 $ 28,774.00 Total $ 310,132.00 $ 916,585.00 $ 126,603.00 $ - $ 1,353,320.00 $ - $ 1,353,320.00 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 Appr Date