ADDACHMENT D REQUEST FOR PAYMENT.PDF

HTF Eviction Prevention- Maricopa County
Attachment D- Page 35
ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT SUMMARY SHEET PAGE 1 OF 2 
Recipient Maricopa County 
Date
Contract No 523-19
Contract Period: from 02/01/2019-06/30/2020 
Pay Req. No/Mo
Activity  HTF Administration, Support Services, Prevention Assistance
Direct Wire Dep
Yes   X    No
Recipient Address 234 N. Central Ave. Suite 3000
City Phoenix
Contact Person Sandra Mendez
ZIP 85004
Phone 602-506-2316
Email Sandra.Mendez@Maricopa.gov
Fax
Program Specialist Chavon Woods
Email Chavon.Woods@azhousing.gov
County Maricopa
Itemized Payment Statement (Sheet 2 of 2) must accompany this form.  Include copies of timesheets and other backup
documentation. ORIGINAL SIGNATURES are required for processing.
a
b
c
d
e
f
g
h
Budget Line Item or
IDIS 
HTF
HUD-COC
Total Amount
Balance in 
Amount of this
New 
Activity No. 
Act No.
2019
Req. to Date
Account
Request
Balance
Act. 1 Administration
$16,187.00
$16,187.00
16,187.00
$                                 
Act. 2 Support Services
$72,913.00
$72,913.00
72,913.00
$                                 
Act. 3 Prevention Assist. 
$390,400.00
$390,400.00
390,400.00
$                               
-
$                      
-
$                                            
-
$                      
-
$                                            
-
$                      
-
$                                            
-
$                      
-
$                                            
-
$                      
-
$                                            
Total 
479,500.00
$             
-
$                      
-
$                    
479,500.00
$          
-
$                     
479,500.00
$                               
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 Approva Date
C-22-19-018-3-02

HTF Eviction Prevention-Maricopa County
ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT -ITEMIZED PAYMENT STATEMENT  PAGE 2 OF 2
Recipient
Date
Contract No    523-18
Contract Period:  from  2/1/2019 to 6/30/2020
Pay Req. No 
Budget Line
Description of 
Paid (or Payable) to
Date 
Check # 
Invoice
Balance 
Name of other
Item or
Expense (List in 
Paid
Invoice
Amount
paid by
source
Activity No
according to 
PO
Charged to
other 
funding source)
COC/HTF
source
Totals