AMENDMENT RE COMMUNITY HEALTH GRANT WITH ADHS.PDF

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ARIZONA STATE CONTRACT
CONTRACT RELEASE
047,/-----
ProcureAZ Purchase Order No.: ADHS12-010921:3
Organizational Reference No.: E0144826
Issued: 01103/2014
11 Vendor Number: 000010983 Arizona Department of Health Services
El Maricopa County Public Health Bureau of Women and Children's Health
NI 4041 N. Central Avenue, #1400 11 150 N. 18th Avenue, Sege 320
Phoenix, AZ 85012 Phoenix, AZ 85007
US
Erna: procuregazdhs.gov
Contract No.: ADHS12i010921 602 364-1400
Title: Community Health Grant
MAIL INVOICE IN DUPLICATE TO:
Et Arizona Department of Health Services
Bureau of Women and Children's Health
150 N. 18th Avenue, Suite 320
I-- Phoenix, AZ 85007
L US
Email: procure©azdhs.gov
r)
(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: 14-99401-43400-6811- -- Payment Terms: Net 30
Shipping Terms:
Solicitation (Bid) No.: Delivery Calendar Day(s)A.R.O.: 0
Item Description I Requisition Quantity Unit Unit Price Total
Class-Item 952-13
PO EFFECTIVE 1/1/14 - 12/31/14* CONTRACT EFFECTIVE 1/1/11 -
12/31/15 "" CONTRACTOR TO INVOICE ACCORDING TO CONTRACT
1 PRICE SHEET AS FOLLOWS: PERSONNEL = $180,147.00*** ERE = 1.00 YR $ 300,000.00 $ 300,000.00
$66,270,00*** PROFESSIONAL & OUTSIDE SERVICES = $1,000.00
TRAVEL EXPENSE = $2,000.00 *" OTHER OPERATING EXPENSE =
$4,052.00 *7 CAPITAL OUTLAY EXPENSE = $0 "'INDIRECT (IF
AUTHORIZED) = $42,931.00 "* OTHER = $3,600.00 *** TOTAL ANNUAL
CONTRACT AMOUNT = $300,000.00 "" Community Health Grant
TOTAL: $ 300,000.00
Approved By: Dee Vlahos
Phone No.: (602) 364-1425

FEDERAL FINANCIAL ASSISTANCE INFORMATION
PR # WCH Index: 99401
Type of Funds being allocated: Federal X State
If Federal Grant Funds are being allocated to fund any part of the service(s) being requested
(ISA/IGA/Contracts/Amendments), the following information must be completed by the Program
Section and attached to the PWO.
GRANT INFORMATION:
a. Grant CFDA Number (or Federal Contract Number if applicable): 93.994
b. Customer Relationship: Contractor/Vendor Sub-recipient(s) X
c, Name of the Federal Financial Assistance (as listed on the Grant):
11ICH BLOCK GRANT
d. Amount of Federal Financial Assistance being allocated to Contractor/Vendor and/or
$300,000
e. ADHS Contract Number: # (To be filled by procurement)
FEDERAL GRANTS COMPLIANCE REQUIREMENTS:
Contractor shall comply with the requirements of 01VIB Circular A-133.
Insert any specific Restrictions and/or Requirements that apply to the Grant:
MCH Block Grant funds awarded to the Arizona Department of Health Services shall not be
used for:
I. Inpatient services, other than inpatient services provided to children with special health
care needs or to high-risk pregnant women and infants and such other inpatient services
approved by the Secretary of the Department of Health and Human Services (DHHS).
2. Cash payments to intended service recipients of Health Services.
3. The purchase or improvements of land; the purchase, construction or permanent
improvement (other than minor remodeling) of any building or other facility; or the
purchase of major medical equipment — unless the State has obtained a waiver from the
Secretary of DHHS.
4. Satisfying any requirement for the expenditure of non-federal funds as a condition for
the receipt of federal funds.
S. Providing funds for research or training to any entity other than a public or non-profit
private entity.
6. Payment for any item of service (other than an emergency item or service) furnished by
or at the medical direction or prescription of an ineligible or uncertified individual or
entity.
NOTE: If volume of information requested exceeds space available on this form, please
reference the applicable Section of the Grant.
* When a sub-recipient relationship exists, the Cash Management Improvement Act of 1990
(CMIA) rules and procedures as noted in the Federal Register, 31 CFR Part 205, must be followed.
In general for the sub-recipient, there must be a receipt and distribution of the cash within two days
unless the cash is used to reimburse for expenditures. The Treasury - State Agreement (TSA)
between the United States Department of the Treasury and the State controls the funding technique
used for the transfer of funds. Any non-compliance with approved funding techniques or the use of
pre-issuance funding will result in an interest liability to the State or the sub-recipient as applicable.
Grant Form G9-1 April 4, 1999