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WEATHERIZATION Attachment D ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT SUMMARY SHEET PAGE 1 OF 2 Recipient Date Contract No 215‐20 Contract Period: from 7/1/2020 to 6/30/2021 Pay Req. No/Mo Activity Direct Wire Dep Yes No Recipient Address City Phoenix Contact Person ZIP 85004 Phone Email Fax 602‐372‐2292 Program Specialist Email County Maricopa Itemized Payment Statement (Sheet 2 of 2) must accompany this form. Include copies of invoices, cashed checks, and other backup documentation. SIGNATURES are required for processing. a b c d d e f g h Budget Line Item or ASAP DOE LIHEAP Source Total Amount Balance in Amount of this New Activity No. No. FY2020 FY2020 Program Year Req. to Date Account Request Balance 1. DOE Administration 57,792.00 $ 57,792.00 $ 57,792.00 $ 2. DOE Training & TA 39,123.00 $ 39,123.00 $ 39,123.00 $ 3. DOE Program Ops 522,483.00 $ 522,483.00 $ 522,483.00 $ 4. DOE Health & Safety 78,300.00 $ 78,300.00 $ 78,300.00 $ 5. DOE Financial Audit ‐ $ ‐ $ ‐ $ 6. DOE Liability Ins ‐ $ ‐ $ ‐ $ 7. DOE Total Draw 0.00 697,698.00 $ 8. LIHEAP Admin. N/A 42,910.00 $ 42,910.00 $ 42,910.00 $ 9. LIHEAP Training/TA N/A 10,700.00 $ 10,700.00 $ 10,700.00 $ 10. LIHEAP Program OpsN/A 973,570.00 $ 973,570.00 $ 973,570.00 $ 11. LIHEAP Total Draw N/A 0.00 1,027,180.00 $ N/A N/A N/A N/A Total 697,698.00 $ 1,027,180.00 $ ‐ $ ‐ $ 1,724,878.00 $ ‐ $ 1,724,878.00 $ Recipient Authorized Signature Date Title Recipient Authorized Signatory certifies that all activities undertaken by the contractor with funds provided under this contract have been carried out in accordance with the contract. Attach wiring information if not previously submitted. Attach alternate mailing address if necessary. Performance Reports Current Not Current For ADOH Use Only ADOH Program Specialist Approval Date ADOH Program Administrator ApproDate REV. 1-2014 Gloria Castro trisha.ekenberg@maricopa.gov gloria.castro@azhousing.gov Maricopa County 234 N. Central Ave., 3rd Floor Trisha Ekenberg 602‐506‐4842 Weatherization Assistance Program