ATTACHMENT B- MONTHLY PAYMENT REQUEST.PDF

Maricopa County Human Services Department
Community Development Division
Payment Request Claim Form
TIME STAMP ABOVE
Subrecipient: Lodestar Day Resource Center Month & Year
Address: 1125 W. Jackson Contract # C-22-15-063-3-00
City/State/Zip: Phoenix, AZ 85007 Contract Start Date April 15, 2015
Contact Person: David Bridge Contract End Date October 31, 2016
Phone Number: 602-223-3419 Date Submitted
E-mail Address: dbridge@hsc-az.org
B. Amount
D. New Total
A. Contract Budget Requested YTD C. Amount of this E. New Balance in
Line Item Expenditures Requested YTD
Amount (from D. previous Request Budget (A-D)
(B+C)
claim)
1. Shelter Operations (4/15/15-11/15/15) $302,892 $ -
2. Shelter Operations (4/15/15-6/30/15) $47,108 $ -
3. Shelter Operations (7/1/15-6/30/16) $190,789 $ -
4. Shelter Operations (7/1/16-10/31/16) $278,383 $ - $ - $ -
TOTALS: $819,172 $ -
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.
Authorized 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.
Supporting documentation MUST be submitted with this claim. No expenses from any prior periods are eligible for reimbursement. Amendment #4 funding
of $376,475 is for eligible expenses for the time period of 07/01/16-10/31/16.
MCHSD/CD USE ONLY
Project Manager Date
Assistant Director Date
Grants Accountant Date