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10/4/21, 3:36 PM MPO List - FY22 - 543 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=543&We… 1/2 SharePoint Main MPO Docs Purchase Order # Change Order Current Encumbrance Original MPO # Requester Name Location Scope Bureau Contract No. Supplier No. Supplier E-mail Supplier Address Date Effective Date Termination Date Sub Total Tax Freight Total Manual Purchase Orders MPO List STATE OF ARIZONA Arizona Department of Health Services Procurement Office 150 N 18th Avenue, Suite 530 Phoenix, AZ 85007 Manual Purchase Order BILL TO: (send invoices to invoices@azdhs.gov) SHIP TO Arizona Department of Health Services Accounts Payable 150 N 18th Ave, Suite 260 Phoenix, AZ 85007 FY22 - 543 Payment Terms NET 30 FOB Destination No Contract Information Christine Wampler ADHS PREP EDC S HIV Prevention EDC IGA2021-051 IV0000002618 k.mason@maricopa.gov Maricopa County Department of Public Helath 4041 N. Central Ave. Phoenix AZ 85012 9/27/2021 8/1/2021 7/31/2022 Line Items Extended Price is calculated by multiplying Quantity by Unit Price. Line Quantity Unit Description Unit Price (#) Extended Price ($) Totals ($) 1 1 YR HEPATITIS C TESTING & PATIENT NAVIGATION IGA#2021-051 $223,664.00 $223,664.00 $223,664.00 2 $0.00 3 $0.00 4 $0.00 $223,664.00 5 $0.00 Calculate Total 6 $0.00 7 $0.00 8 $0.00 9 $0.00 10 $0.00 C-86-21-050-X-01 10/4/21, 3:36 PM MPO List - FY22 - 543 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=543&We… 2/2 Encumbrance Distribution is attached Does this form contain Federal Funding? Encumbrance Total ($) GAE # All PDS signed? Encumbrance Distribution No No Line BFY Function Dept. Obj Unit PPC Amount (#) CFDA# 1 2022 FEDEDC8168 6811 5135 0722 $223,664.00 93.940 2 3 4 5 6 $223,664.00 22*1242 No Any off-contract MPOs over $10k require Procurement Disclosure Statements (PDS) be attached CFDA Information: Contractor shall comply with the 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 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. FOR COUNTY: ______________________________ Jack Sellers, Chairman Date Board of Supervisors APPROVED AS TO FORM: _______________________________ Attorney for County Date ATTEST: _______________________________ Office of the Clerk of the Board Date