10-17 - Attachment L - Request for Payment.docx

This is a Request for Payment form issued by the City of Dallas Office of Housing and Community Empowerment (OHCE) for use by contractors participating in the Drivers of Poverty/Drivers of Opportunity Program, which is funded through Community Development Block Grant (CDBG) resources. The form serves as a billing statement template that contractors must submit to request reimbursement for services rendered under their subrecipient agreements with the City. The document is designed to capture detailed cost information across multiple budget categories, including salaries, benefits, supplies, marketing, and equipment expenses, with fields for both current period expenses and cumulative totals organized by year-to-date reporting.

The form requires contractors to document actual reimbursable costs associated with the provision of services in accordance with their contract terms and to certify that all required documentary evidence has been submitted. Contractors must provide contract identification information, encumbrance numbers, vendor numbers, and accounting codes, along with calculations showing the contract amount, amount requested, current amount due, payments received to date, payments in transit, total contract payments to date, and remaining funds available. The form includes approval checkboxes for payment authorization and requires signatures from the contractor, a Contract Compliance Administrator, and a Contract Compliance Supervisor, with a revision date of February 3, 2026.