205-20 MARICOPA COUNTY SWG FY20 (D) REQUEST FOR PAYMENT.PDF

SWG WEATHERIZATION
Attachment D
ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT SUMMARY SHEET PAGE 1 OF 2 
Recipient
Date
Contract No 205-20
Contract Period: from 1/1/2020 to 12/31/2020
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
SWG
Source
Source
Total Amount
Balance in 
Amount of this
New 
Activity No. 
 No.
FY2020
Program Year
Program Year
Req. to Date
Account
Request
Balance
1. DOE Administration
-
$                   
-
$                         
2. DOE Training & TA
-
$                   
-
$                         
3. DOE Program Ops
-
$                   
-
$                         
4. DOE Health & Safety
-
$                   
-
$                         
5. DOE Financial Audit
-
$                   
-
$                         
6. DOE Liability Ins
-
$                   
-
$                         
7. DOE Total Draw
0.00
8. LIHEAP Admin. 
N/A
-
$                   
-
$                         
9. LIHEAP Training/TA
N/A
-
$                   
-
$                         
10. LIHEAP Program OpsN/A
-
$                   
-
$                         
11. LIHEAP Total Draw N/A
0.00
12. SWG Admin.
N/A
7,838.00
$           
-
$                   
7,838.00
$           
7,838.00
$                
13. SWG Program Ops.
N/A
59,057.00
$         
-
$                   
59,057.00
$         
59,057.00
$              
14. SWG Health/Safety
N/A
19,324.00
$         
-
$                   
19,324.00
$         
19,324.00
$              
15. SWG Total Draw
N/A
0.00
Total 
86,219.00
$         
-
$                   
-
$                   
-
$                   
86,219.00
$         
-
$                   
86,219.00
$              
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

F-4
ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT -ITEMIZED PAYMENT STATEMENT  PAGE 2 OF 2
Recipient
Date
Contract No 205-20
Pay Req. No
Budget Line item
Description of 
Paid (or Payable) to
Date 
Check # 
Invoice
Balance 
Name of other
(DOE, LIHEAP, SWG)
Expense (List in 
Paid
Invoice
Amount
paid by
source
 &
according to 
PO
Charged to
other 
Job No
funding source)
DOE/SWG/LIHEAP
source
Totals
Maricopa County