APS CRISIS BILL ASSISTANCE PROGRAM 2022.PDF
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APS Crisis Bill Assistance Program Page 1 of 13 P.O. NO. 700805367 AGREEMENT BETWEEN APS AND MARICOPA COUNTY FOR CRISIS BILL ASSISTANCE This Agreement, effective retroactively on January 1, 2022 (“Effective Date”), is by and between Arizona Public Service Company, an Arizona corporation, with offices at 400 North 5th Street, Phoenix, Arizona 85004 (“APS”) and Maricopa County, administered by its Human Services Department, with offices at 234 North Central Avenue, Phoenix, Arizona 85004 (“Contractor”). Contractor and APS may each individually be referred to herein as a Party and collectively as the Parties. RECITALS Whereas, APS has agreed to provide up to $180,170 (“Program Funds”) to fund the Special Crisis Bill Assistance Program for APS customers in crisis whose incomes are less than or equal to 200% of the Federal Poverty Level guidelines; and Whereas, APS enters this Agreement with Contractor to have Contractor administer and disburse a portion of the Program Funds, as further described below. Therefore, in consideration of the recitals set forth above, the respective agreements of the Parties herein set forth, and other good and valuable consideration the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows: AGREEMENT I. TERM/TERMINATION The term of this Agreement commences as of the Effective Date and terminates on December 31, 2022 (“Term”) unless terminated earlier by either Party in accordance with the terms hereof. This Agreement is subject to A.R.S. § 38-511, the pertinent provisions of which are incorporated here by this reference. Additionally, APS shall have the ability to cancel this Agreement at any time during the term with 60 days written notice to Counterparty. II. SCOPE OF SERVICES A. Program Coordination. The program provided for under this Agreement shall be referred to as the Crisis Bill Assistance Program (“Program”). On behalf of APS, Contractor will administer and disperse any Program Funds allocated to Contractor under this Agreement to provide crisis bill assistance to eligible limited-income households and individuals residing in APS’s service territory in accordance with the terms of this Agreement. Contractor may rely upon the service territory maps available through APS’s website (https://www.aps.com) to determine whether a household is located within APS’s service territory. B. During the Term, Contractor will perform the following services: APS Crisis Bill Assistance Program Page 2 of 13 1. Administer any Program Funds allocated to it and distribute them in accordance with the terms hereof; 2. Serve as a central point of contact for all activities reasonably necessary to implement the services contemplated in this Agreement including, but not limited to, remittance of payments, invoicing, tracking, auditing, and reporting; 3. Ensure that Program Funds available to Contractor are fully distributed to eligible limited-income customers by the end of the Agreement Term; 4. Recommend implementation timelines and oversee the development and operation of specific Program procedures with input from, and subject to APS review; 5. Monitor and oversee all Program activities and prepare timely monthly reports of such activities; 6. Review and verify that all general and financial criteria for eligibility for limited income assistance as provided for in this Agreement are adhered to; 7. Ensure that all Program related forms are completed and reviewed for accuracy, including all audit forms used for customer qualification, and any other verification calculations and documentation agreed upon in writing by the Parties; 8. Answer questions about the Program and resolve customer complaints relating to the Crisis Bill Assistance from the Program. Issues related to APS customer billing, account status, etc. will be relayed to APS or the customer can contact APS directly; 9. Represent APS fairly to APS customers involved in the Crisis Bill Assistance process and to local media, including, without limitation, presentations for the Maricopa County Board of Supervisors, limited income conferences, community events and other public presentations; 10. Fully utilize APS’s Electronic Agency Guarantee (“EAG”) portal. This includes using EAG to approve customers for Program funds and enrolling eligible customers into APS’s Energy Support program as the standard practice. Also, when making a guarantee a source for the funds, the appropriate fund selection shall be selected from the drop-down options to track the source of funds. 11. Perform such other administrative tasks as to which the Parties agree in writing from time to time during the Term of this Agreement. C. Program Eligibility: 1. Other than the administrative fees discussed in V.A. below, Program Funds dispersed pursuant to this Agreement shall only be provided by Contractor to, or on behalf of, eligible limited-income individuals or households on their active APS account. To be eligible to receive Program Funds, an individual and/or household must meet the following income requirements and be experiencing a crisis situation as defined below: APS Crisis Bill Assistance Program Page 3 of 13 a. Income requirements. Eligible individuals and/or households shall have a maximum gross household income less than or equal to 200% of the Federal Poverty Level (“FPL”) as defined by the Arizona Department of Economic Security (“DES”), as adjusted annually by DES. For purposes of this Agreement, a “Household” is defined as group of individuals in a single residence for which energy is purchased in common. b. Crisis Situation. A customer is in a “crisis situation” if the customer meets all of the following criteria: i. must be a resident of Arizona; ii. must not be a resident of an institution. Institutions include: (a) hospitals; (b) licensed domiciliary care facilities (family care homes, homes for the aged, and family care homes for developmentally disabled adults); (c) intermediate care facilities; (d) skilled nursing facilities or homes; (e) alcohol and drug rehabilitation centers or treatment program; (f) dormitories; (g) temporary protective facilities, such as domestic violence shelters, etc.; or (h) prisons; iii. for a resident of public housing, the individual must have an obligation to pay the utility bill directly to APS on an ongoing basis; and iv. the eligible individual must have had: (i) a loss or reduction of income which places him/her within the range prescribed in Section II.C.1(a), above; (ii) unexpected or unplanned expenses that caused a lack of resources; or (iii) a condition has occurred or exists that endangers the health or safety of the Household of which the individual is a member; and v. the customer provides acceptable crisis situation documentation of the crisis situation. As there are many crisis situations, the supporting documentation will vary. Here are some examples (not an exhaustive list) of documents that provide proof of crisis: (a) loss of employment or reduction of hours: letter of termination from employer or paystub showing reduction in hours; (b) medical emergency or issue: doctor’s note or current medical bill, ER discharge notes; APS Crisis Bill Assistance Program Page 4 of 13 (c) unexpected expense documents such as: i. bill related to the expense (car repair bill/estimate); ii. utilities shut off or delinquency notice; iii. eviction notice; and iv. other letter or document demonstrating the additional financial burden; and (d) victim of crime: police report or referral from a domestic violence agency where individual participates. 2. A Household or individual who meets all eligibility requirements set forth above may receive up to $800 to cover a current or past-due APS bill, but may not receive Program Funds to pay APS bills incurred at former residences. A Household or individual is eligible for bill assistance payments twice during a 12-month period starting with the awarding of the first bill assistance payment. The total amount of Program Funds awarded to an individual and/or household during a 12-month rolling period cannot exceed $800. Additionally, Program Funds may not be used to pay deposits. 3. Customer Authorization. Prior to approving and submitting a customer for assistance, Contractor will ensure that the aps customer has accepted (via signature, telephonic or digital approval) an approved consent form allowing Contractor to access information from APS concerning the customer’s relevant account information or other information needed to assist the customer. III. REPORTING REQUIREMENTS A. Reporting Requirements: 1. To ensure that the Program Funds are promptly distributed to customers who meet the criteria in II.C. above within the Term that the Program Funds are allocated, Contractor is required to track and report monthly on several metrics and performance measures as described in this Agreement. 2. During the Term, Contractor will submit monthly reports to APS detailing Program performance on a Monthly Spending Detail Report (Report). The Report must be sent to APS by the 20th of each month for the month prior. 3. The Monthly Spending Detail Report must contain at a minimum the following information: a. An excel file that lists for the Contractor and/or each QPA: i. Direct Services amount by customer ii. Administrative fee amount by customer, if applicable iii. Application date by customer iv. Customer name v. Customer address vi. Customer APS account number APS Crisis Bill Assistance Program Page 5 of 13 vii. Total funds distributed for Direct Services and Administrative fees to date for the entire Term. viii. Program Fund balance b. Contractor will send the Spending Detail Report via the APS secure Microsoft Teams site or through the Contractor’s secure file transfer site. 4. Failure to timely submit required Reports and other information that may be reasonably requested by Aps pursuant to this Agreement may be grounds for termination of this Agreement. IV. BILL ASSISTANCE ALLOCATION, PROMOTION, TRAINING AND AUDITS A. During the Term of this Agreement Contractor is eligible to receive up to a total of $180,170 of Program Funds as described below: 1. APS will provide Program Funds in accordance with Section V Compensation/Taxes below. 2. Contractor administrative costs will come from the Program Funds. 3. Contractor will distribute Program Funds until they are depleted. 4. Contractor will invoice APS monthly for the prior month’s activity. 5. Contractor will fully utilize the Electronic Agency Guarantee (EAG) portal features as defined by APS in the EAG Agency contract to distribute Program Funds. 6. Contractor and APS shall meet at least monthly to review Program status. B. APS Program Promotion: 1. APS will utilize its internal and external resources to provide a reasonable amount of Program promotion. This will include posters, flyers, newsletters, printing and other items as necessary to build customer awareness regarding the availability of Program funds. APS will obtain prior written consent before distribution of promotional materials using the Contractor name and/or logo. C. APS Training Support for Contractor: 1. APS will utilize its internal and external resources to provide a reasonable amount of training for Contractor personnel regarding the Program. This will include in-person and/or online training and reference materials. D. Auditing of records: 1. APS shall have the right to audit all books and records related to the Program upon five (5) business days’ prior written notice to Contractor. Notwithstanding requirements contained in this Agreement to the contrary, Contractor may redact or withhold records that contain legally protected confidential information pertaining to individual recipients of Program Funds, such as social security numbers as well as attorney-client and work- product communications and information. APS Crisis Bill Assistance Program Page 6 of 13 V. COMPENSATION/TAXES A. In exchange for providing the services contemplated in this Agreement, Contractor is entitled to receive as its administrative fee 20% of each allocation of Program Funds paid to it if it is fully utilizing the APS EAG system. B. Contractor shall be responsible for any taxes that may be levied, or imposed upon it as a result of the transactions contemplated by this Agreement. C. Each month Contractor shall submit an original invoice containing the purchase order number # 700805367 provided for this transaction, an adequate description of the Services, and a detailed breakdown of the invoice amount, shall be accompanied by reasonable documentation and shall be submitted to APS Company email at each of the following: payables@aps.com michelle.lehman@aps.com james.holbrook@aps.com D. The time for payment of invoices will run from the later of the date Company receives correct invoices for Services (Receipt Date). APS shall pay Contractor within 15 days of the Receipt Date. E. APS will pay approved invoices via electronic transfer. VI. GENERAL TERMS AND CONDITIONS A. Handling of Personally Identifiable Information (PII) Information. For the purpose of this Agreement PII includes any information that permits the identity of an individual to be directly or indirectly inferred, including any information that is linked or linkable to that individual. Examples of PII include, but are not limited to name, address, customer account numbers, and addresses. Contractor should limit its access to PII to the greatest extent possible. To the extent Contractor obtains PII generated or received in connection with the Program from individual or household recipients of Program Funds or from any other source, Contractor shall handle all such PII in a confidential manner and have appropriate processes and procedures in place for handling PII such in a secure and confidential manner. Upon request, Contractor shall provide a description of such processes and procedures to APS. B. Warranties. Each Party warrants that the activities performed pursuant to or in furtherance of this Agreement shall be performed in compliance with all applicable laws, rules, regulations, codes, standards, ordinances and orders of regulatory authorities having jurisdiction over the activities contemplated by this Agreement. C. Independent Contractor. The Parties will act as independent contractors and neither Party will act as agent for or partner of the other Party for any purpose whatsoever, and the employees of one will not be deemed employees of the other. Nothing in this Agreement will grant to either Party, the right to make commitments of any kind for or on behalf of the other Party without prior written consent of the other Party. D. Limitation of Liability. Neither Party nor its respective officials, officers, directors, departments, agencies, boards, committees, commissions, employees, APS Crisis Bill Assistance Program Page 7 of 13 volunteers, agents, advisors, representatives, parents, affiliates, successors or assigns shall be liable to the other Party for any indirect, consequential, special, punitive or exemplary damages for any actions resulting from or arising out of this Agreement, whether based on contract, tort (including, but not limited to, negligence), strict liability, professional liability, contribution, or otherwise, provided, however, that this limitation of liability shall not apply to: (a) the reciprocal indemnity obligations of the Parties as set forth in section VI.E, Indemnification, below, or (b) losses arising from a breach of the respective confidentiality obligations of the Parties under Section VI.G, Confidentiality and Advertising. E. Indemnification. Each Party (as "Indemnitor") agrees to indemnify, defend, and hold harmless the other Party (as "Indemnitee") from and against any and all claims, losses, liability, costs, or expenses (including reasonable attorney fees) (hereinafter collectively referred to as "Claims") arising out of the negligent performance of this Agreement, but only to the extent that such Claims which result in vicarious/derivative liability to the Indemnitee are caused by the act, omission, negligence, misconduct, or other fault of the Indemnitor or its directors, departments, agencies, boards, committees, commissions, employees, volunteers, agents, advisors, representatives, parents, and affiliates. F. Insurance Coverages. Without limiting the Contractor’s indemnification obligations, the Contractor shall provide and maintain the following insurance coverages, using forms and insurers acceptable to APS, and require its contractors and subcontractors who perform work with respect to the Program to carry the same coverages: 1. Workers’ Compensation insurance covering obligations imposed by federal, state, and local statutes with jurisdiction over the Contractor’s (and any of its contractor’s or subcontractor’s) employees and Employer’s Liability insurance with limits of One Million Dollars ($1,000,000) per accident for bodily injury by accident, One Million Dollars ($1,000,000) per employee for bodily injury by disease and One Million Dollars ($1,000,000) and One Million Dollars ($1,000,000) policy limit for bodily injury by disease; 2. Commercial General Liability insurance with a combined single limit of One Million Dollars ($1,000,000) each occurrence, and Two Million Dollars ($2,000,000) general and products-completed operations aggregate. The policy shall cover bodily injury, property damage, personal injury, contractual liability, and products and completed operations; and 3. Business Automobile Liability insurance with limits of One Million Dollars ($1,000,000) each occurrence with respect to the Contractor’s (and any of its contractor’s or subcontractor's) vehicles, whether owned, hired, or non- owned, assigned to or used in connection with performance of the Program. 4. Data Protection/Cyber Liability insurance with limits not less than One Million Dollars ($1,000,000) per claim and in the aggregate covering liabilities resulting or arising from acts, errors, or omissions in rendering Services or in connection with the Agreement. Coverage must include, but not be limited to: damages Contractor is obligated to pay Company or any APS Crisis Bill Assistance Program Page 8 of 13 third party associated with a Security Incident or associated with loss of PII or Confidential Information; costs to notify individuals whose PII was lost or compromised; and costs to provide credit monitoring and credit restoration services to individuals whose PII was lost or compromised regardless of cause (including, without limitation, Contractor’s negligence or gross negligence and unlawful third party acts). Such policy must provide coverage for wrongful acts, claims, and lawsuits anywhere in the world and must be kept in force during the term of the Agreement and for three (3) years after completion, cancellation or termination of the Agreement. All required policies held by Contractor, with the exception of the Worker’s Compensation, shall name APS as an additional insured. Such policies shall stipulate that the insurance shall be primary insurance and that any insurance carried by APS shall not be contributory insurance. The Contractor and its insurers providing the required coverages shall waive all rights of recovery against APS, and their directors, officers, employees, and agents. In the event the Contractor purchases insurance policies required by this Section that are not occurrence based policies, Contractor shall either (a) maintain claims made policies for at least 3 years following termination of this Agreement, or (b) obtain extended discovery periods for any claims made policies for at least three (3) years following termination of this Agreement. Further, all policies required by this Section, except for Workers’ Compensation, shall contain a severability of interest provision, and shall not contain any commutation clause or any other provision that limits third party actions over claims. Upon APS’s request, the Contractor shall provide documentary evidence in a form and content reasonably acceptable to APS, confirming to its reasonable satisfaction that the required insurance coverages have been obtained and will remain in effect as required by this Section. G. Confidentiality and Advertising. All nonpublic information that one Party may provide to another Party or that a Party acquires from any source in connection with this Agreement shall be deemed to be confidential information (collectively called, Confidential Information). Confidential Information includes, but is not limited to: (a) customer specific information, including, without limitation, customer’s utility bill information history; (b) any reports, specifications, know-how, strategies or technical data, processes, business documents or information, market research or other data, customer or client lists, and all other information concerning the business and affairs of a Party that are owned, used, or possessed by or for the benefit of a Party; (c) intellectual property of a Party; and (d) customer information or materials obtained by a Party from a third party in connection with performance of its obligations under this Agreement. Neither Party will not provide customer confidential information or PII to the other Party without written customer consent. The Contractor shall not make copies, reproductions, abstracts or excerpts of the Confidential Information in whole or in part, except as authorized by APS or as contemplated by this Agreement (including, without limitation, Contractor’s production of Reports), nor use such information except as contemplated by this Agreement. All copies, reproductions, excerpts or abstracts of Confidential Information are deemed to be Confidential Information to the same extent as any originals. Upon the expiration of the Term or the earlier termination of the APS Crisis Bill Assistance Program Page 9 of 13 Agreement, the Contractor shall promptly return to APS all Confidential Information and all copies thereof or other physical embodiments of the Confidential Information. The Contractor agrees that any and all of the Confidential Information shall be maintained in confidence by the Contractor indefinitely. Confidential Information may not be disclosed by the Contractor to any person other than the Contractor’s personnel, employees or agents who require knowledge of the APS Confidential Information in order to perform their respective obligations under this Agreement. The Contractor further agrees that such Confidential Information shall be used solely in connection with the Contractor’s performance of its obligations hereunder, and for no other purpose, and that all persons to whom the Contractor discloses the Confidential Information shall be advised of its confidential nature and of the Contractor’s obligations of confidentiality and non-use under this Agreement. The Contractor shall be responsible for any disclosure or use of Confidential Information by persons to whom Contractor provided the Confidential Information that is not in accordance with this Agreement. The name and logo of APS or any of its affiliates shall not be used in any advertising or other promotional context by the Contractor or its contractors or subcontractors without the prior written consent of APS (which may be withheld by APS in its sole discretion). H. Dispute Resolution/Attorneys’ Fees. If a dispute arises concerning this Agreement, a meeting of the Parties shall be held within ten (10) business days after either Party gives the other Party written notice of the dispute (the Dispute Notice). The Dispute Notice shall set forth in reasonable detail the aggrieved Party’s position and its proposal for resolution of the dispute. A representative of each Party who has authority to resolve the dispute shall be in attendance at all meetings of the Parties initiated in connection with a Dispute Notice. If the dispute is not resolved within thirty (30) calendar days after the first meeting of the Parties, either Party is free to use any other available remedy, including litigation. The Dispute Notice and 30-day discussion period are conditions precedent to each Party’s right to resort to any other method of dispute resolution, including litigation. A Party's failure to comply with this Section shall entitle the other Party to recover its costs and reasonable attorney fees in any judicial proceedings that circumvent this dispute resolution provision. The prevailing Party in any proceedings instituted by either Party regarding a dispute concerning this Agreement shall be entitled to recover its reasonable attorney fees and taxable costs and expenses as allowed for and defined under Arizona law. I. Severability. If any term or condition of this Agreement is held to be invalid, void, or otherwise unenforceable by any court of competent jurisdiction, that holding shall not affect the validity or enforceability of any other term or provision of this Agreement, unless enforcing the balance of this Agreement would deprive either party of a fundamental benefit of its bargain. J. Disclaimer of Third Party Beneficiaries. There are no persons or entities other than those who are signatory to this Agreement such are intended to be benefited by the terms contained herein and except to the extent a person or entity is entitled to indemnification pursuant to Section VII.E, all third-party beneficiaries are hereby disclaimed. APS Crisis Bill Assistance Program Page 10 of 13 K. Survival. Termination of this Agreement shall not relieve either Party of any obligation under this Agreement which expressly or by implication survives termination of this Agreement, including its obligations under the following section headings: Insurance Coverages, Indemnification, Limitation of Liability, Warranties, Records and Auditing, Confidentiality and Advertising, Governing Law, Dispute Resolution/Attorney's Fees. L. Entire Agreement. This Agreement contains the final and complete agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous conduct, agreements, statements, representations, negotiations, course of conduct, course of dealing, and communications pertaining to such matters, whether written or oral. M. Governing Law. This Agreement shall be governed by and interpreted in accordance with the laws of the State of Arizona and of the United States without giving effect to the doctrine of conflict of laws. This Agreement shall be deemed made and entered into in Maricopa County, Arizona. Any suit to enforce this Agreement shall be instituted only in the Superior Court of Maricopa County, Arizona, or the Federal District Court for the District of Arizona, and such Courts shall have the exclusive jurisdiction over any such suit or suits. N. Notices and Designated Representatives. All notices required to be given by this Agreement will be given in person, by certified United States Mail, postage prepaid, return receipt requested, by facsimile transmission, by reputable overnight delivery service, or by email (confirmed by regular mail). All notices shall be deemed given when received. Notices shall be directed to the Parties as follows: If to APS: Arizona Public Service Company P.O. Box 53999 Mail Station 8028 Phoenix, Arizona 85072-3999 Designated Representative: James Holbrook Phone: (602) 250-2683 Cell: (623) 810-4419 Email: James.Holbrook@aps.com If to Contractor: Maricopa County Human Services Dept. 234 North Central Avenue Phoenix, Arizona 85004 Designated Representatives: Name, Title: Cathy Chiang, Assistant Director, Community Services Division Phone: (602) 506-4206 Email: Cathy.Chiang@Maricopa.gov Notices shall be effective: (a) on the date delivered by personal delivery, facsimile, or electronic mail; (b) three (3) business days following the date deposited in the United States mail; or (c) the next business day following delivery to a reputable overnight delivery service. Notices and communications shall be delivered or mailed to the Parties’ designated representatives named above. Designated representatives of either Party may be changed at any time by providing the other Party prior written notice of such change. O. Assignment. Neither Party will assign, transfer or otherwise dispose of its rights or obligations under this Agreement or any interest therein, without the other Party's APS Crisis Bill Assistance Program Page 11 of 13 prior written consent, which will not be unreasonably withheld, conditioned, or delayed. P. Amendments and Modifications. This Agreement can be modified or amended only by a writing signed by both Parties or their duly authorized agents. No course of dealing or oral changes between the Parties will be effective or legally binding as an amendment to this Agreement. Q. Records and Auditing. Contractor shall maintain accurate and complete records relating to its performance of this Agreement, including, without limitation, accounting records that support its reports to APS under this Agreement and administration and disbursement of Program Funds. These records, with the exception of attorney-client and work-product communications and information, shall be retained by Contractor and be reasonably available for inspection and audit by APS for four (4) years after completion or termination of this Agreement. R. Waiver. A Party’s failure or delay in enforcing the terms and conditions of this Agreement or in insisting upon strict performance of any of the other Party’s obligations shall not be interpreted as a waiver thereof. Waiver of any provision of this Agreement by either Party shall only be effective if in writing and shall not be interpreted as a waiver of any subsequent breach or failure under the same or any other provision of this Agreement. No conduct, statement, course of conduct course of dealing, oral expression, or other action shall be construed as a waiver. APS Crisis Bill Assistance Program Page 12 of 13 IN WITNESS WHEREOF, this Agreement has been executed by the Parties as of the Effective Date. MARICOPA COUNTY: Bill Gates Date Chairman, Board of Supervisors ARIZONA PUBLIC SERVICE COMPANY: (signature) Attested to: Juanita Garza Date Clerk of the Board (signature) Approved as to Form: Deputy County Attorney Date (signature) APS Crisis Bill Assistance Program Page 13 of 13 Attachment A – Customer Utility Information Release Authorization UTILITY INFORMATION RELEASE AUTHORIZATION By signing this form, I authorize Arizona Public Service Company (“APS”) to release my historical and future utility bills, account information (such as, but not limited to, name, social security number, service address, account number, balance, payment history, rate) and other information concerning or related to energy consumption, costs and account information necessary to enable my household to qualify for this and additional utility, food or shelter assistance programs to any and all of the agencies/persons list on this form (“Authorized Parties”). This release is granted in connection with my household’s request for and/or receipt of assistance from the community agency listed below. I understand and agree that the utility information released may be compiled and analyzed (both on an individual and combined basis) by one or more of the Authorized Parties. I further understand and agree that the utility information released, as well as any statistical or other analysis, may be released by the Authorized Parties to a third party for reporting purposes related to assistance received, and no information shall be made public in such a manner that my dwelling or household occupants can be identified. I further agree to release and hold harmless the above-named utility provider(s) from: (i) any claims, damages, liability or expenses resulting from the use or disclosure of information based on this Authorization; (ii) the unauthorized use or disclosure of the information by any of the Authorized Parties; and (iii) any actions taken by any of the Authorized Parties based on this Authorization. Authorized Parties: Community Agency: Name of agency determining assistance: Maricopa County administered by its Human Services Department Signature of Account Holder/Customer of Record ________________________ Print Account Holder/Customer of Record ______________________________ Service Address __________________________________________________ Account Number __________________________________________________ Date ___________________________________________________________