HomeMy WebLinkAbout08/19/2019 Item 014Arizona
Department
of Housing
HOPWA TBRA
Attachment D Page 31
ARIZONA DEPARTMENT OF HOUSING REQUEST FOR PAYMENT SUMMARY SHEET PAGE 1 OF 2
Recipient Mohave County Community Services Department Date
Contract No 516-19 Contract Period: from 10/01/2018 to 09/30/2020 Pay Req. No/Mo
Activity HOPWA, TBRA, Supportive Services, Administration Direct Wire Dep Yes No
Recipient Address 700 West Beale Street / PO Box 7000 City Kingman
Contact Person Dave Wolf ZIP 86402-7000
Phone 928-753-0723 Email
Dave.Wolf(a)-mohavecountv.us Fax 928-753-0776
Program Specialist Ryan Vernick Email
Ryan.Vernick(a azhousinq.gov CountyMohave
Itemized Payment Statement (Sheet 2 of 2) must accompany this form. Include copies of invoices, cashed checks, and other backup
documentation. ORIGINAL SIGNATURES are required for processing.
a b c d e f g h
Budget Line Item or IDIS HOPWA SOURCE Total Amount Balance in Amount of this New
Activity No. Act No. 2018 Program Year Req. to Date Account Request Balance
TBRA 6253 $ 82,400.00 $ 82,400.00 $ 82,400.00
Permanet Housing Placement (PHP) 6392 $ 20,000.00 $ 20,000.00 $ 20,000.00
Supportive Services 6254 $ 27,075.00 $ 27,075.00 $ 27,075.00
Administration 6252 $ 9,063.00 $ 9,063.00 $ 9,063.00
$ - $ -
Total $ 138,538.00 $ - $ I $ 138,538.00 1 $0.00 $ 138,538.00
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