13-Attachment K- Request for Payment Form.pdf
PDF 96 KB Posted
- Attached to
- Eviction Advocacy Program
- Solicitation number
- BEZ26-00029663
- Issued by
- Dallas County, Texas
About this file
This is a Request for Payment form issued by the City of Dallas Office of Housing and Community Empowerment (OHCE) for the Eviction Advocacy Program. The form serves as a billing statement template for contractors administering the program, which provides legal support and representation to Dallas residents facing eviction. The contract term is one year with one optional one-year renewal, and the program is designed to serve vulnerable tenants at no cost to clients while supporting stable and accessible housing as part of the City's Drivers of Opportunity policy framework.
The payment form captures cost categories including salaries, benefits, supplies, marketing, and equipment expenses, with columns for budget amounts, expenses for the current reporting period, cumulative totals, and year-to-date figures. Contractors must report the contract amount, amount requested for payment, current amount due, previous payments received, payments in transit, total contract payments to date, and remaining funds. The form requires contractor certification that all expenses represent actual reimbursable costs in accordance with contract terms and that required documentary evidence has been submitted, with approval required from both the Contract Compliance Administrator and Contract Compliance Supervisor.
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Text version
Attachment K
Office of Housing and Community Empowerment Program Name
Request for Payment
Contractor: Reporting Period:
Encumbrance No.:
Address: Vendor No.:
AA No.:
Telephone: Term:
I. Cost Categories
Budget Amount
Expenses This Period
Cumulative Total
Year-to-Date
SALARIES:
Salaries $ $ $
Benefits
Subtotal $ $ $
OTHER DIRECT COSTS:
Supplies/Marketing $ $ $
Equipment $ $ $
Subtotal $ $ $
TOTAL DIRECT COSTS $ $ $
Indirect Costs
TOTAL COSTS $ $ $
II. Contract Amount $ Amount of this Request $
CURRENT AMOUNT DUE $
Payments Received to Date $
Payments in Transit $
Total Contract Payments to Date $
FUNDS REMAINING $
CERTIFICATION
I certify that this billing statement reflects actual reimbursable costs associated with the provision of services in accordance with the terms of the contract between and the City of Dallas. I also certify that all required documentary evidence has been submitted along with the billing statement in accordance with the procedures established by the City of Dallas.
Signature Date
Payment Authorized:
[ ] Yes [ ] No
Contract Compliance Administrator Date
Approved:
Contract Compliance Supervisor Date
File details come from the government source that posted it. Updated .