SIGNED INV RE PMT WITH CITY OF MESA FD.PDF
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MESA FIRE CHILDHOOD IMMUNIZATION PROGRAM REPORT OF SERVICES DELIVERED AND INVOICE Machrina Leach 1. IGA Number: C-86-07-058-2 4041 North Central, Suite 600 2. Contractor: Mesa Fire Department Mesa Fire and Medical Department Phoenix, Arizona 85012 Deputy Cheif: Jerome Schirmer 3. Program: Childhood Immunization Amendment 4 4. Period: 06/03/12- 05/31/13 Invoice# 05-13 FIXED PRICE Rate per Unit Number of Units Provided Total Funds Earned this Prior Report Period Year to Total Year to Date Funds this Reporting Period Reporting Period Date Funds Earned Earned A. Type of Unit: ( 1 ) ( 2) ( 3) ( 4) ( 5) June 3, 20-'1 2- May 31 , 2013 $ 15.00 5,105 $ 76,575.00 $ - $ 76,575.00 TOTAL $ 76,575.00 CONTRACTOR CERTIFICATION I certify that this report has been examined by me, and to the best of my knowledge and belief, the reported expenditures and fixed price information is valid, based upon our official VFC Accountability and Ordering Form and is consistent with the terms of the contract. It is also understood that the contract payments are calculated by the Maricopa County Department of Public Health based 1 upon information provided in this report. I Larissa Dvorak Program As Program Coordinator A ' :;::> Auth0rizatif1 ~