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150 N. 18th Avenue, Phoenix, AZ 85007 BILL TO: (send invoices to invoices@azdhs.gov) SHIP TO Arizona Department of Health Services Accounts Payable 150 N 18th Ave, Suite 530 Phoenix, AZ 85007 Manual Purchase Order Type: Service(s) MPO #: MPO20250134 Is this a change order?: Y Current Encumbrance: Original MPO #: FY25-1537 Is this to close the MPO?: N Request Basic Information: Requestor Email: arlis.jenkins@azdhs.gov Location Scope (Site) ADHS PREP BIDS S HEPATITIS C Bureau BIDS Contract No. IGA2021-051 Supplier Name Maricopa County Department of Public Health Supplier ID IV0000002618 Supplier Email CHERYL.BUCALO@MARICOPA.GOV Supplier Address Maricopa County Department of Public Health 301 W Jefferson St 9th Floor Phoenix AZ 85003 Date 8/8/2025 Effective Date 6/1/2025 Termination Date 7/31/2025 Line Items: Line Quantity Description Unit Price (#) Extended Price ($) 1 Hepatitis C Testing at the Maricopa County Department of Public Health STI Clinic $70,000.00 $70,000.00 Totals ($) Sub Total $70,000.00 Tax $0.00 Freight $0.00 Total $70,000.00 Encumbrance Distribution: PPC or BFY Function Dept. Object Unit Funding Amount CFDA# 2605 FEDBID2035 6811-Aid to Counties 5235 $70,000.00 Encumbrance Total ($) $70,000.00 GAE # 250000002094 CFDA Information (if applicable): Contractor shall comply with requirements of OMB Circular. For grant restrictions, refer to https://www.ecfr.gov/cgi-bin/text-idx? tpl=/ecfrbrowse/Title02/2cfr200_main_02.tpl Federal Funding Accountability and Transparency Act If applicable, the Contractor/Grantee shall submit to ADHS via email the Grant Reporting Certification Form. This form and the instructions and the instructions can be downloaded below and must be returned to the ADHS by the 15th of the month following that in which the award was received. The form shall be completed electronically, and submitted using the steps outlined in the Grant Reporting Certification Form Instructions and emailed to us. All required fields must be filled including Top Employee Compensation, if applicable. Completing the Grant Reporting Certification Form is required for compliance with the Office of Management and Budget (OMB). Failure to timely submit the Grant Reporting Certification Form could result in the loss of funds. This requirement applies to all subcontractors/sub-awardees utilized by the Contractor/Grantee for amounts exceeding $30,000.00 during the term of the Award.