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ARIZONA STATE CONTRACT CONTRACT RELEASE ProcureAZ Purchase Order No.: ADHS13-034910:3 Organizational Reference No.: PO0000017092 Issued: 08/17/2015 C-86-13-050-3-05 V Vendor Number: 000010983 Arizona Department of Health Services E Maricopa County Public Health S Bureau of Tobacco and Chronic Disease N 4041 N. Central Avenue, #1400 H 150 N. 18th Avenue, Suite 310 Phoenix, AZ 85012 I Phoenix, AZ 85007 D US O P Email: procure@azdhs.gov R T O Contract No.: ADHS13-034910 (602) 364-0824 Title: BTCD Maricopa HIV Prevention (PO 07/01/15 - 06/30/16) MAIL INVOICE IN DUPLICATE TO: B Arizona Department of Health Services I Bureau of Tobacco and Chronic Disease 150 N. 18th Avenue, Suite 310 L Phoenix, AZ 85007 L US Email: procure@azdhs.gov T O (602) 364-0824 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: 2016--FEDPHS2067--4513--HS2000--HS20000-6811---PHS-EDC- Payment Terms: Net 30 HIVPREV--1216---------HSA Shipping Terms: Delivery Calendar Day(s) A.R.O.: 0 Item Description Requisition Quantity Unit Unit Price Total Class-Item 952-43 1 1.00 TOTAL $ 147,394.00 $ 147,394.00 HIV Prevention - Partner Services Part A Class-Item 952-43 2 1.00 TOTAL $ 68,607.00 $ 68,607.00 HIV Prevention - Testing Part A Class-Item 952-43 3 HIV Prevention - Supplemental Part B 1.00 TOTAL $ 183,149.00 $ 183,149.00 CFDA# 93.940 (100% Federal Funding) Purchase Order for the Period 07/01/2015 - 06/30/2016 Items 1 - 3 represent 50% funding 1 ARIZONA STATE CONTRACT CONTRACT RELEASE Class-Item 952-43 4 1.00 TOTAL $ 199,575.00 $ 199,575.00 HIV Prevention - Partner Services Part A Item 4 Represents an additional 25% funding. (02.16.16) Class-Item 952-43 5 1.00 TOTAL $ 182,717.00 $ 182,717.00 HIV Prevention - Part A Services Class-Item 952-43 6 1.00 TOTAL $ 16,857.00 $ 16,857.00 HIV Prevention - Supplemental Part B Item 5 - 6 represent the remaining 25% approved funding Item 5 - 6 (CFDA# 93.940 (100% Federal Funds) TOTAL: $ 798,299.00 Approved By: Byron Homer Phone No.: (602) 364-1223 2 C-86-13-050-3-05 ATTACHED TO AND A PART OF Purchase Order ADHS13-034910:3 Contract No. ADHS13-034919 BTCD Maricopa Prevention (PO 07/01/15- 06/30/16) IN WITNESS WHEREOF, the parties agree to enter into this Contract: FOR AND ON BEHALF OF MARICOPA COUNTY By Clint Hickman Chairman, Board of Supervisors Date ATTEST: Clerk of the Board Date APPROVED AS TO FORM: Attorney for Maricopa County Date 3