15-Attachment H- Request for Payment.xlsx
XLSX spreadsheet 34 KB Posted
- Solicitation number
- OCC-2025-00028249
- Issued by
- Dallas County, Texas
About this file
This document is a Request for Payment attachment for the Housing Opportunities for Persons with AIDS (HOPWA) program, issued by the City of Dallas Office of Community Care. The contract involves providing housing assistance and supportive services for low-income persons living with HIV, with funding from the U.S. Department of Housing and Urban Development (HUD). The scope includes multiple service categories such as Emergency/Tenant Based Rental Assistance, Facility Based Housing, Emergency Vouchers, Master Leasing, Housing Information Services, Supportive Services, and Facility Rehabilitation/Repair.
The payment request form outlines detailed budget tracking for financial assistance, support services, and administrative costs, with monthly reporting requirements. Contractors must submit payment requests within 20 days after the reporting period, with a submission window closing 30 days after contract expiration. The document specifies that cost categories must align with the approved budget, with a total budget revision limit of 20% of the contract amount. The form includes sections for tracking expenses, program income, certification of reimbursable costs, and a leverage/match expenditure report to ensure comprehensive financial accountability.
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Text version
1-Procedures
| Attachment H |
| Project Sponsor's Name |
| Housing Opportunities for Persons with AIDS (HOPWA) |
| Request fo Payment Procedures | ||
| I. | PROCEDURES | |
| A. | CONTRACTOR shall submit the Request for Payment, Exhibit D, Page 2, accompanied by the appropriate Proofs of Performance, Exhibit F, on a monthly basis. Reports are due within twenty (20) days after the end of the reporting period. Late submissions may result in delayed or non-payments. The submission window closes 30 days after the contract expiration date. | |
| B. | CONTRACTOR will ensure that expenses billed do not exceed the approved budgeted amount. | |
| C. | All documents should be submitted to: | |
| Office of Community Care | ||
| 1500 Marilla, 6BN | ||
| Dallas, TX 75201 | ||
| D. | Request for Payment forms and/or Proofs of Performance documentation will be examined for completeness, consistency, accuracy and compliance with the terms of the corresponding CITY contract. | |
| E. | Requests for Payment and/or Proof of Performance, which are incomplete, inconsistent, inaccurate, or not in compliance with contract requirements, will result in a delay in processing the payment. | |
| F. | Cost categories must be consistent with the budget itemized in Exhibit D, Pages 2-3 and approved by the CITY. Completion of a Budget Revision Request Form, Exhibit D, Page 5, is required if expenditures of program operations are not consistent with the approved contract budget. A total budget revision cannot exceed 20% of the total contract amount and must be approved in advance by the CITY. |
&"Calibri,Bold"Exhibit D, Page 1 of 5
2-Request for Payment
| Revised |
| Attachment H |
| Office of Commuity Care |
| Request for Payment |
| Contractor: | Period (Mo/Yr): |
| Vendor No. | MASC No. |
| Address: | AA/Resolution No. |
| Term: | |
| Telephone: | CFDA No: |
| I. Cost Categories | Budget | ||
| Amount | Expenses This Period | Cumulative Total Year-to-Date |
| Emergency/Tenant Based Rental Asst | |
| (Financial Asst & Support Services) | |
| (Delivery Order No. ___________) | $0.00 |
| Administrative Costs | |
| (Delivery Order No. ___________) | $0.00 |
TOTAL HOPWA BUDGET (14.241): $0.00 $0.00 $0.00
| II. Total Not to Exceed Contract Amount | $0.00 | |
| Amount of this Request | $0.00 | |
| Less: Program Income/Fees/Applicable Credits | ||
| CURRENT AMOUNT DUE | $0.00 | |
| Payments Received to Date | $0.00 | |
| Payments in Transit | $0.00 | |
| Total Contract Payments to Date | $0.00 | |
| FUNDS REMAINING | $0.00 |
III. Program Income/Fees/Applicable Credits YTD $0.00
| 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 Contractor 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. |
Authorized Representative Date
| Payment Authorized: | ||
| [ ] Yes [ ] No | ||
| Contract Compliance Administrator | Date: |
| Approved By: | ||
| Contract Compliance Manager | Date: |
&"Calibri,Bold"Exhibit D, Page 2 of 5
3-Request for Payment Detail
| Revised Attachment H |
| Project Sponsor's Name |
| Housing Opportunities for Persons with AIDS (HOPWA) |
FY25-26 Request for Payment Detail
Month/Year:
BUDGET LINE ITEMS ARE DESCRIBED IN MORE DETAIL IN THE BUDGET ATTACHMENT
| EMERGENCY/TENANT BASED RENTAL ASST - FINANCIAL ASSISTANCE | ||||||||||||||||
| E/TBRA - FINANCIAL ASSISTANCE | BUDGET | OCT | NOV | DEC | JAN | FEB | MAR | APR | MAY | JUN | JUL | AUG | SEPT | YTD | FUNDS REMAINING | Progress |
| TBRA/Tenant Based Rental Asst | $0.00 | $0.00 | ERROR:#DIV/0! | |||||||||||||
| STRMU/Emergency Asst | $0.00 | $0.00 | ERROR:#DIV/0! | |||||||||||||
| TOTAL | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ERROR:#DIV/0! |
| EMERGENCY/TENANT BASED RENTAL ASST - SUPPORT SERVICES | |||||||||||||||||
| E/TBRA - SUPPORT | |||||||||||||||||
| SERVICES | BUDGET | OCT | NOV | DEC | JAN | FEB | MAR | APR | MAY | JUN | JUL | AUG | SEPT | YTD | FUNDS REMAINING | Progress | |
| Salaries | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Fringe Benefits | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Staff Travel* | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Equpment | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Supplies | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Contractual-IT | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Occupancy | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Communicatons | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Printing | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Postage | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Equipment Rent & Maintenance | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Liability Insurance | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| TOTAL | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ERROR:#DIV/0! | |
| *Staff Travel beyond standard mileage rate subject to prior approval by City of Dallas | |||||||||||||||||
| ADMINISTRATIVE COSTS | |||||||||||||||||
| ADMINISTRATIVE COSTS | BUDGET | OCT | NOV | DEC | JAN | FEB | MAR | APR | MAY | JUN | JUL | AUG | SEPT | YTD | FUNDS REMAINING | Progress | |
| Salaries | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| Fringe Benefits | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| HMIS Costs | $0.00 | $0.00 | ERROR:#DIV/0! | ||||||||||||||
| TOTAL | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ERROR:#DIV/0! | |
| *Staff Travel beyond standard mileage rate subject to prior approval by City of Dallas |
| TOTAL | ||||||||||||||||
| TOTAL | BUDGET | OCT | NOV | DEC | JAN | FEB | MAR | APR | MAY | JUN | JUL | AUG | SEPT | YTD | FUNDS REMAINING | Progress |
| E/TBRA - Financial Assistance | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ERROR:#DIV/0! |
| E/TBRA - Support Services | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ERROR:#DIV/0! |
| Administrative Costs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ERROR:#DIV/0! |
| Total | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ERROR:#DIV/0! |
| Target | 8% | 17% | 25% | 33% | 42% | 50% | 58% | 67% | 75% | 83% | 92% | 100% | ||
| Administrative Cap (budget) | ERROR:#DIV/0! | Administrative Cap (actual at year end) | ERROR:#DIV/0! | |||||||||||
| (cannot exceed 7.0%) | (cannot exceed 7.0%) | |||||||||||||
| (Over)/Under (actual at year end) | $0.00 |
&"Calibri,Bold"Exhibit D, Page 3 of 5
4-LevMatchReport
| Revised Attachment H |
| Project Sponsor's Name |
| Housing Opportunities for Persons with AIDS (HOPWA) |
Leverage/Match Expenditure Report
Period (Mo/Yr):
| Please indicate the source, description, and the cost category (e.g., housing, supportive services, administration, etc.) for all matched or leveraged funds. | |||||||||||||||||
| Source & Cost Category for Leverage/Match Funds | Description | Goal | Oct | Nov | Dec | Jan | Feb | Mar | Apr | May | June | July | Aug | Sep | YTD | Remaining | Progress |
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
| TOTAL | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ERROR:#DIV/0! |
&"Calibri,Bold"Exhibit D, Page 4 of 5
5-BudgetRevision
| Attachment H |
| Project Sponsor's Name |
| Housing Opportuniteis for Persons with AIDS (HOPWA) |
Budget Revision Request Form
| AGENCY NAME: | ||||
| Project Description: | ||||
| Contract Period: | ||||
| Cost Category | Original | |||
| Budget | Change | |||
| Requested | Revised |
Budget
Reason for requested change:
Signature of Authorized Executive Date
| Printed Name | ||
| Request Approved/Denied | ||
| City of Dallas Representative | Date |
&"Calibri,Bold"Exhibit D, Page 5 of 5
6-BudgetAttachment
| Revised Attachment H |
| Project Sponsor's Name |
| Housing Opportuniteis for Persons with AIDS (HOPWA) |
Budget Attachment
File details come from the government source that posted it. Updated .