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4/11/24, 8:29 AM MPO List - FY24 - 1257 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=1257&Web=b61612d1-e2fa-43e0-b368-9e5ef5495991 1/4 SharePoint Main MPO Docs Manual Purchase Orders MPO List 4/11/24, 8:29 AM MPO List - FY24 - 1257 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=1257&Web=b61612d1-e2fa-43e0-b368-9e5ef5495991 2/4 Purchase Order # Change Order Current Encumbrance Original MPO # Requester Name Location Scope Bureau Contract No. Supplier Name Supplier ID (APP#) or Vendor ID (AFIS #) Supplier E-mail Supplier Address Date Effective Date Termination Date 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 FY24 - 1257 Payment Terms NET 30 FOB Destination No Contract Information Mitchell Goldberg ADHS PREV BWCH S Childrens Health BWCH RFGA2022-003-007 MARICOPA COUNTY DEPT OF PUBLIC HEALTH IV0000029389 della.killeen@maricopa.gov 4041 N Central Ave. Suite 1400 Phoenix, AZ 85012 4/8/2024 10/1/2023 9/30/2024 Line Items Extended Price is calculated by multiplying Quantity by Unit Price. 4/11/24, 8:29 AM MPO List - FY24 - 1257 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=1257&Web=b61612d1-e2fa-43e0-b368-9e5ef5495991 3/4 Sub Total Tax Freight Total Encumbrance Distribution is attached Does this form contain Federal Funding? Encumbrance Total ($) GAE # All PDS signed? Line Quantity Unit Description Unit Price (#) Extended Price ($) Totals ($) 1 1 EA HOME VISITING SERVICES PER ATTACHED PRICE SHEET $1,555,368.77 $1,555,368.77 $1,555,368.77 2 $0.00 $0.00 3 $0.00 $0.00 4 $0.00 $1,555,368.77 5 $0.00 Calculate Total 6 $0.00 7 $0.00 8 $0.00 9 $0.00 10 $0.00 Encumbrance Distribution Yes Yes Line BFY Function Dept. Obj Unit PPC Amount (#) CFDA# 1 2024 FEDCFH1770 6811 0924 $1,555,368.77 93.870 2 3 4 5 6 $1,555,368.77 240000003008 No Any off-contract MPOs over $10k require Procurement Disclosure Statements (PDS) be attached 4/11/24, 8:29 AM MPO List - FY24 - 1257 https://sharepoint.hs.azdhs.gov/Procurement/mpo/Lists/MPO Dev/fd_Item_Display.aspx?List=15e3e237-e41f-4979-9dde-c36f799e3703&ID=1257&Web=b61612d1-e2fa-43e0-b368-9e5ef5495991 4/4 CFDA Information( if applicable ): 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.