Exhibit_C_-_Contractor_s_Invoice_and_Statement_of_Expenditures.xlsx

XLSX spreadsheet 438 KB Posted Aug 1, 2024

Attached to: Master Agreement AZ|CTR072894
Contract number: CTR072894
Issued by: Arizona

About this file

Written by GovTribe AI · Oct 3, 2025

This document is a Contractor's Invoice and Statement of Expenditures form from the Arizona Department of Economic Security, specifically for the Community Action Human Resources Agency. The document involves multiple state agencies including the Division of Aging and Adult Services, Office of Community Partnerships and Innovative Practices, and various local and regional organizations such as Catholic Charities, Arizona Community Action Association, City of Phoenix Human Services Department, and numerous food banks, shelters, and social service providers across Arizona.

The contract (Contract ID: E6306014) appears to cover multiple service categories including community action programs, domestic violence programs, coordinated homeless services, hunger programs, and refugee resettlement. The invoice template is designed to track expenditures across different budget categories like personnel, services, travel, space, equipment, and indirect costs. The document lists numerous sub-contractors and partner organizations, suggesting a comprehensive network of social service providers receiving funding through this state contract. The invoicing form allows for detailed tracking of units served, client information, and funding sources including CSBG, TANF, ESG-P, and LIHEAP, indicating a multi-funded approach to delivering social services across Arizona.

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Other files

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CTR072894_-_WC_Endorsement__1_.pdf	PDF	Aug 1, 2024
CTR072894_-_WC_Endorsement__2_.pdf	PDF	Aug 1, 2024
CTR072894_Debarment_Checks.pdf	PDF	Aug 1, 2024
Exhibit_B-_HUMAN_GUIDE_Techniques.pdf	PDF	Aug 1, 2024
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Attachment_4_-_Service_Delivery_Area_Baraka_House_REVISED.pdf	PDF	Aug 1, 2024
CTR072894_Contract_Amendment_1.pdf	PDF	Aug 1, 2024
CTR072894_Contract_Documents.pdf	PDF	Aug 1, 2024
Exhibit_D1_-_DERS_Monthly_Activity_Detail.xlsx	XLSX spreadsheet	Aug 1, 2024
2-Attachment_3_-_Transportation_Services_Rate_Sheet_Baraka_House_BAFO.pdf	PDF	Aug 1, 2024
CTR072894_-_COI_and_Endorsements__1_.pdf	PDF	Aug 1, 2024
CTR072894_-_WC_COI__1_.pdf	PDF	Aug 1, 2024
CTR072894_-_WC_COI__2_.pdf	PDF	Aug 1, 2024
Exhibit_D2_-_DAAS_Monthly_Activity_Detail.xlsx	XLSX spreadsheet	Aug 1, 2024

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2.57	8.43	11.71	14.14	14.00	14.00	14.00	14.00	14.00	RESET CELL WIDTH WITH THESE VALUES
Worksheet has been formatted to allow you only to Tab to cells that are eligible/available for your contract billing.
FW-110 (REV 4/12/10)				CONTRACTOR'S INVOICE

Arizona Department of Economic Security	I. Contractor Name:
Division of Aging and Adult Services
	Community Action Human Resources Agency
Attn: CONTRACT MANAGEMENT UNIT	II. DES Contract ID Number:	E6306014
P.O. Box 6123 Site Code 086Z
Phoenix, AZ 85005-6123	III. Service Delivery

Date (Mo./Yr):

IV. Original Supplemental

Page 1 of _______

		Service:-A CMT		Service:-B		Service:-C
V.	Budget Categories	Total Cost	DAAS Cost	Total Cost	DAAS Cost	Total Cost	DAAS Cost
1	Personnel
2	E.R.E.
3	Pro. & Outside Svcs.
4	Travel
5	Space
6	Equipment
7	Materials & Supplies
8	Operating Services
9	Indirect Costs
10	Subtotal Admin Cost	0.00	0.00	0.00	0.00	0.00	0.00
11	Vouchers
12	Total Costs	0.00	0.00	0.00	0.00	0.00	0.00
13	Rate

VI.	Other Information
1	Units
2	Clients
3	TANF Eligible Families Served					Applicable to Setup and Page 1
3A	NUMBER OF FAMILIES
4	TANF Non-Fed Expend (MOE)					Unlocked for data entry per active budget categories (per ISB(s)
5	Voucher Type:	DAAS Cost	DAAS Cost	DAAS Cost		Unlocked for Data Entry
						locked and hidden cells
	CSBG
	ESG-P
	TANF
	LIHEAP
					Formula(s)

VII. Contractor Information		VIII. Payment Information		For Budget based only
Prepared By:	Title	Total Amount Requested	Voucher Fund Names

Date Prepared		Phone No.			Amount Paid (DAAS use only)	CSBG
						CSBG ARRA
Transaction #	INVOICE #:		IX. ESG Expenditures			ESG-P
			Column A:	$		HML
			Column B:	$		SSBG
			Column C:	$		TANF
(Reserved for DAAS Use Only)						TANHML
						LIHEAP

Against Abuse, Inc.	DES-60034-013
Against Abuse, Inc.	DES-60036-002
Area Agency on Aging Region One, Inc.	DES-60034-007
Arizona Children's Association	E1224017
Arizona Coalition Against Domestic Violence	DES-70507-001
Arizona Coalition to End Homelessness	DES-70509-001
Arizona Community Action Association	DE0-71057-001
Arizona Community Action Association	DES-60004-001
Arizona Community Action Association	DES-70508-001
Arizona Community Action Association 3	DE0-71057-001
Arizona Community Action Association2	DES-60004-001
Arizona Department of Commerce	E6306019
Arizona State University	DE1-01123-001
Association of Arizona Foodbanks, Inc.	DES-70506-001
Association of Arizona Foodbanks, Inc.	DES-60011-002
Bisbee Coalition for the Homeless	DES-70068-005
Bisbee Coalition for the Homeless	DES-60004-003
Borderland Food Bank	DES-60011-003
Catholic Charities Community Services, Inc.	DES-60011-004
Catholic Charities Community Services, Inc.	DES-60011-005
Catholic Charities Community Services, Inc.	DES-60034-011
Catholic Charities Community Services, Inc.	DES-60036-018
Catholic Charities Community Services, Inc.	E6306010
Catholic Charities Community Services, Inc.	DE0-70010-002
Catholic Community Services of Southeastern AZ	DES-60036-010
Catholic Community Services of Southern AZ	DES-60011-006
Central Arizona Shelter Services, Inc.	DES-60034-010
Chicanos Por La Causa	DES-60036-011
Chicanos Por La Causa	DES-60034-005
Chrysalis Shelter for Victims of Domestic Violence	DES-60036-003
Chrysalis Shelter for Victims of Domestic Violence	E6305018
Chrysalis Shelter for Victims of Domestic Violence	DE0-71131-001
City of Phoenix Human Services Department	DES-60011-007
City of Phoenix Human Services Department	E6306004
City of Phoenix Human Services Department	E6306011
Coconino County Community Services Department	DES-60034-004
Colorado River Regional Crisis	DES-60036-014
Colorado River Regional Crisis	DES-60011-008
Community Action Human Resources Agency	E6306014
Community Action Human Resources Agency	DES-60036-005
Community Alliance Against Family Abuse	DES-60004-004
Community Food Bank	DEO-70046-001
Community Food Bank, Inc.	DEO-70057-001
Community Food Bank, Inc.2	DEO-70050-001
Community Food Bank, Inc.3	DEO-70049-001
Community Food Bank, Inc.4	DEO-70059-001
Community Food Bank, Inc.5	DE0-70331-001
Community Information & Referral, Inc.	DES-60011-009
Crossroads Mission	E6306015
Gila County Community Action Program	DES-60011-010
Good Neighbor Alliance	DES-60757-001
Governor's Office for Child, Youth and Families	DES-60036-008
Horizon Human Services	DES-60011-011
Information and Referral	DE0-70222-001
Interfaith Coalition for the Homeless	DES-71065-001
Interfaith Coalition for the Homeless	E1224018
Jewish Family & Children's Services of Southern Arizona, Inc.	DES-60036-017
Kingman Aid to Abused People, Inc.	DEO81064-001
Lodestar Day Resource Center, Inc.	E6306022
Maricopa Association of Governments	E6306005
Maricopa County Human Services	DES-60011-012
Mesa Community Action Network, Inc.	DES-71039-001
Mesa Community Action Network, Inc.	DES-60036-015
Mt. Graham Safe House, Inc.	DES-60011-013
New Beginnings for Women & Children	DES-60034-002
New Hope Ranch	DES-60036-016
New Life Center	DES-60011-014
Northern Arizona Council of Governments	E6306012
Northern Arizona Council of Governments	DES-60036-020
Northland Family Help Center	DES-60024-001
Open Inn, Inc.	DES-60011-015
Our Family Services, Inc.	DE0-71513-001
Page Regional Domestic Violence Service	DES-60013-002
Phoenix Indian Center	DES-60004-005
Phoenix Revitalization Corporation	E6306007
Pima County Community Service Department	DES-60004-006
Portable Practical Education Preparation	E6306009
Portable Practical Education Preparation	DES060011-016
PREHAB of Arizona, Inc.	DES-60034-008
PREHAB of Arizona, Inc.	DES-60035-001
PREHAB of Arizona, Inc.	DES-60036-006
PREHAB of Arizona, Inc.	DES-60011-017
Primavera Foundation, Inc.	DES-60011-018
Save the Family Foundation of Arizona	DES-60011-019
Social Services Interagency Council of Lake Havasu City	DES-80005-001
Social Services Interagency Council of Lake Havasu City	DES-60011-020
Society of St. Vincent de Paul	DES-60034-012
Sojourner Center	DES-60036-023
Sojourner Center	DES-60004-007
Southeast Arizona Food Bank, Inc.	E6306016
Southeastern Arizona Community Action Program	E1224010
Southern Arizona Legal Aid, Inc.	DEO-70044-001
St. Mary's Food Bank Alliance	DEO-70047-001
St. Mary's Food Bank Alliance	DEO-70053-001
St. Mary's Food Bank Alliance	DEO-70054-001
St. Mary's Food Bank Alliance	DEO-70055-001
St. Mary's Food Bank Alliance	DEO-70060-001
St. Mary's Food Bank Alliance	DES-60004-011
St. Mary's/Westside Food Bank Alliance	DES-70502-001
The Arizona Foundation for Legal Services and Education	DES-60036-021
The Brewster Center Domestic Violence Services	DES-60036-001
The Salvation Army	DES-60011-022
The Salvation Army/ Tucson	DES-60034-003
Time Out, Inc.	DES-60036-013
Time Out, Inc.	DES-60036-022
Tohdenasshai Committee Against Family Abuse, Inc.	E6306018
Tohono O'Odham Nation	DES-60011-023
Travelers Aid Society of Tucson	DES-60034-001
Tucson Centers for Women and Children	DES-60036-004
Tucson Centers for Women and Children	E6306008
Tucson Urban League, Inc.	DE0-70010-001
UMOM New Day Centers, Inc.	DES-60011-024
UMOM New Day Centers, Inc.	DEO-70045-001
United Food Bank	DEO-70048-001
United Food Bank	DEO-70052-001
United Food Bank	DEO-70056-001
United Food Bank	DEO-70058-001
United Food Bank	DES-60004-008
United Food Bank	DE0-70217-001
University of Arizona	E6306020
University Physicians, Inc.	DES-60036-019
Valley Youth Organization, Inc.	DES 060034 006
Verde Valley Sanctuary, Inc	DES 060036 012
Verde Valley Sanctuary, Inc	DES-60034-006
Verde Valley Sanctuary, Inc.	DES-60036-012
Verde Valley Sanctuary, Inc.	DES 060034 009
WestCare Arizona	DES 060036 007
WestCare Arizona	E6305036
WestCare Arizona	DES-60034-009
Westcare Arizona 1, Inc.	DES-60036-007
Westcare Arizona 1, Inc.	E6306013
Western Arizona Council of Governments	DES-60004-009
Westside Food Bank	E6306032
Westside Food Bank	DES 060036 009
White Mountain Association for Victims of Domestic Violence	E6305037
White Mountain Association for Victims of Domestic Violence	DES-60011-025
Women's Transition Project, Inc.	E6306057
Women's Transition Project, Inc.	DEO-70051-001
Yuma Community Food Bank	DES-60004-010
Yuma Community Food Bank	E6306033
Yuma Community Food Bank	DES-60011-026
YWCA of Maricopa County	E6306058
YWCA of Maricopa County

How many?

SetUp2

2.57	8.43	11.71	14.14	14.00	14.00	14.00	14.00	14.00	RESET CELL WIDTH WITH THESE VALUES
Worksheet has been formatted to allow you only to Tab to cells that are eligible/available for your contract billing.
FW-110 (REV 7/2007)		CONTRACTOR'S INVOICE AND STATEMENT OF EXPENDITURES

		Arizona Department of Economic Security			I. Contractor Name:
		Office of Community Partnerships
		and Innovative Practices			Community Action Human Resources Agency
		Attn: CONTRACT MANAGEMENT UNIT			II. DES Contract ID Number:		E6306014
		P.O. Box 6123 Site Code 086Z
		Phoenix, AZ 85005-6123			III. Service Delivery
Date (Mo./Yr):						Program Name
									ATTN: COMMUNITY ACTION PROGRAM
					IV.	Original	Supplemental		ATTN: DOMESTIC VIOLENCE PROGRAM
									ATTN: COORDINATED HOMELESS PROGRAM
							Page 1 of _______		ATTN: COORDINATED HUNGER PROGRAM
									ATTN: REFUGEE RESETTLEMENT PROGRAM
			Service:-D		Service:-E		Service:-F
	V	Budget Categories	Total Cost	CPIP Cost	Total Cost	CPIP Cost	Total Cost	CPIP Cost
	1	Personnel
	2	E.R.E.
	3	Pro. & Outside Svcs.
	4	Travel
	5	Space
	6	Equipment
	7	Materials & Supplies
	8	Operating Services
	9	Indirect Costs
	10	Subtotal Admin Cost	0.00	0.00	0.00	0.00	0.00	0.00
	11	Vouchers
	12	Total Costs	0.00	0.00	0.00	0.00	0.00	0.00
	13	Rate

VI	Other Information
1	Units
2	Clients
3	TANF Eligible Families Served
3A	Number of Families
4	TANF Non-Fed Expend (MOE)
5	Voucher Type:	CPIP Cost	CPIP Cost	CPIP Cost

						*
						CSBG
						URRDAP
						ESG-P
						HML
VII. Contractor Information					VIII. Payment Information	TANF
Type or Print your Name		Title			Total Amount Requested	TANHML
						LIHEAP
Signature		Date Signed	Phone No.		Amount Paid (CPIP use only)	LLVG
						URRD
Transaction #	INVOICE #:		IX. ESG Expenditures			LIHCON
			Column A:	$
			Column B:	$
			Column C:	$
(Reserved for CPIP Use Only)

Against Abuse, Inc	E6305009
Arizona Children's Association	E1224007
Arizona Coalition Against Domestic Violence	E6305012
Arizona Coalition to End Homelessness	E6306027
Arizona Community Action Association 1	E6306023
Arizona Community Action Association 2	E6306060
Arizona Department of Commerce	E6306019
Arizona Foundation for Legal Service and Education	E6301116
Association of Arizona Foodbanks, Inc.	E6306024
Association of Supportive Child Care	E6304016
Betania Communtiy Center	E6304008
Bisbee Coalition Against Homelessness	E6306034
Borderland Food Bank	E6306025
Catholic Community Services in Southeastern AZ, Inc (Cochise)	E6305015
Catholic Community Services in Southern AZ (WA)	E6305014
Catholic Community Services of Southern Arizona 1 gg	E6304012
Catholic Community Services of Southern Arizona 2 gg	E6304020
Catholic Social Service of Central & Northern Arizona NEW	E6306035
Catholic Social Service of Central & Northern AZ (East Valley)	E6305016
Catholic Social Service of Central and Northern AZ jm	E6305008
Catholic Social Service of Central and Northern Arizona	E6306036
Catholic Social Services of Central and Northern AZ	E6304018
Catholic Social Services of Central and Northern AZ	E6304009
Catholic Social Services of Yavapai 1	E6306010
Catholic Social Services of Yavapai 2	E6306037
Central Arizona Shelter Services	E6306038
Chicanos Por La Causa,Inc 1	E6305038
Chicanos Por La Causa,Inc 2	E6305017
Chrysalis Shelter for Victime of Domestic Violence, Inc	E6305018
City of Mesa	E6306006
City of Phoenix	E6306004
City of Phoenix	E6306039
City of Phoenix Human Serivces Department	E6303004
Coconino County Community Services Dept	E6306011
Colorado River Regional Crisis Shelter, Inc	E6305019
Community Action Human Resource Agency 1	E6306014
Community Action Human Resource Agency 2	E6306040
Community Allicance Against Family Abuse	E6305013
Community Food Bank, Inc	E6306026
Crossroads Mission	E6306041
Department of Education	E6306021
Gila County Division of Health & Comm Svs	E6306015
Good Neighbor Alliance	E6306042
Governor's Office for Child, Youth Family	E6306003
Havasupai Tribe	E6306017
Information & Referral Service, Inc	E6306043
International Rescue Committee 1	E6304019
International Rescue Committee 2	E6304013
International Rescue Committee 3	E6304017
International Rescue Committee 4	E6304011
Jewish Family and Children's Service of Southern Arizona	E6304014
Kingman Aid to Abused People, Inc	E6305021
Lutheran Social Ministry of the Southwest 1	E6304015
Lutheran Social Ministry of the Southwest 2	E6304010
Maricopa Association of Governments	E6306022
Maricopa County Human Services	E6306005
Maricopa County Department of Public Health	E6305001
Melvin L Cohen, MD	E6305041
MESA Community Action Network, Inc.	E6306044
Mt Graham Safe House, Inc	E6305022
NEW BEGINNINGS for Women and Children	E6306046
New Hope Ranch	E6305023
New Life Center	E6305024
Northern Arizona Council of Governments 1	E6306012
Northern Arizona Council of Governments 2	E6306045
Northland Family Help Center	E6305025
OUR TOWN Family Center	E6306047
Page Task Force Against Domestic Violence	E6305026
Phoenix Indian Center	E6306059
Phoenix Revitalization Corporation	E6306028
Pima County Community College District	E6304021
Pima County Community Services Department	E6306007
Portable Practical Education Preparation 1	E6306009
Portable Practical Education Preparation 2	E6306029
Prehab of Arizona, Inc 1	E6303017
Prehab of Arizona, Inc 2	E6305027
Prehab of Arizona, Inc 3	E6306048
The Primavera Foundation, Inc	E6306049
S/S INTERAGENCY Council of Lake Havasu City	E6306053
SAVE THE FAMILY Foundation of Arizona	E6306051
Scott N Calev, DDS	E6305040
Sojourner Center	E6305028
Southeast Arizona Food Bank, Inc.	E6306030
SouthEastern Arizona Community Action Program	E6306016
Southern Arizona Legal Aid, Inc	E1224010
Society of St Vincent De Paul	E6306052
The Brewster Center Domestic Violence Service, Inc 1	E1224011
The Brewster Center Domestic Violence Service, Inc 2	E6305029
The SALVATION ARMY	E6306050
The Salvation Army Phoenix	E6305030
The SALVATION ARMY/TUCSON	E6306054
The Write Advantage	E6304023
Time Out, Inc	E6305031
Tohdenasshai Committee Against Family Abuse, Inc	E6305032
Tohono O'Odh Am Nation	E6306018
Travelers Aid Society of Tucson, Inc	E6306055
Tucson Center of Women and Children 1	E1224012
Tucson Center of Women and Children 2	E6305033
Tucson Urban League	E6306008
United Food Bank	E6306031
UMOM New Day Centers	E6306056
University Physicians, Inc.	E6306020
Valley Youth Organization, Inc	E6305034
Verde Valley Sanctuary, Inc	E6305035
WestCare Arizona	E6305036
Western Arizona Council of Governments	E6306013
Westside Food Bank	E6306032
White Mountain Association for Victims of Domestic Violence	E6305037
Women's Transition Project, Inc.	E6306057
Yuma Community Food Bank	E6306033
YWCA of Maricopa County	E6306058

How many?

Invoice

Worksheet has been formatted to allow you only to Tab to cells that are eligible/available for your contract billing.
FW-110 (REV 4/15/2024)	CONTRACTOR'S INVOICE AND STATEMENT OF EXPENDITURES

Arizona Department of Economic Security	I. Contractor Name:
Contracts Unit		Contractor FEIN:

	II. ADES Contract Number:
Instructions: Submit your completed
invoice electonically or as directed	III. Service Delivery

Date (Mo./Yr):

by your Contracts Unit

IV. Invoice Type

VI.	Client Name:	V.	Division/ Program Name
VII.	Authorization/PO Number:		Other
				Page 1 of __1__

		LOCAL Transportation	DISTANT Transportation
VIII.	Service Provided & Units
1	Ambulatory Transportation	$1.00	$1.00
	Units (Mile)	0	0
Ambulatory Transportation Total		$0.00	$0.00
2	Flag Drop Ambulatory Transportation	$1.00	$1.00
	Units (Each)	0	0
Flag Drop Ambulatory Transportation Total		$0.00	$0.00
3	Ambulatory (Passenger Van 8+ Passengers) Transportation	$1.00	$1.00
	Units (Mile)	0	0
Ambulatory (Passenger Van 8+ Passengers) Transportation Total		$0.00	$0.00
4	Flag Drop Ambulatory (Passenger Van 8+ Passengers) Transportation	$1.00	$1.00
	Units (Each)	0	0
Flag Drop Ambulatory (Passenger Van 8+ Passengers) Transportation Total		$0.00	$0.00
5	Non-Ambulatory (Wheelchair Van) Transportation	$1.00	$1.00
	Units (Mile)	0	0
Non-Ambulatory (Wheelchair Van) Transportation Total		$0.00	$0.00
6	Flag Drop Non-Ambulatory (Wheelchair Van) Transportation	$1.00	$1.00
	Units (Each)	0	0
Flag Drop Non-Ambulatory (Wheelchair Van) Transportation Total		$0.00	$0.00
7	Attendant	$1.00	$1.00
	Units (Hour)	0	0
Attendant Total		$0.00	$0.00
8	Wait Time	$1.00	$1.00
	Units (Minute)	0	0
Wait Time Total		$0.00	$0.00
9	No Show	$1.00	$1.00
	Units (Each)	0	0
No Show Total		$0.00	$0.00
10	Total Costs	Total Local Cost	Total Distant Cost
		$0.00	$0.00

IX. Monthly Activity Detail Report Attached (Yes/No)

X. Contractor Information		VIIII. Payment Information
Prepared By:	Title	Total Amount Requested
		$0.00
Date Prepared	Phone No.	Amount Paid (ADES use only)

Purchase Authorization/Release Order or Purchase Orders # INVOICE #:

(Reserved for ADES Use Only)

Page2

2.57	8.43	11.71	14.14	14.00	14.00	14.00	14.00	14.00	RESET CELL WIDTH WITH THESE VALUES
Worksheet has been formatted to allow you only to Tab to cells that are eligible/available for your contract billing.
FW-110 (REV 7/2007)		CONTRACTOR'S INVOICE AND STATEMENT OF EXPENDITURES

Arizona Department of Economic Security	I. Contractor Name:
Office of Community Partnerships
and Innovative Practices	Community Action Human Resources Agency
Attn: CONTRACT MANAGEMENT UNIT	II. DES Contract ID Number:	E6306014
P.O. Box 6123 Site Code 086Z
Phoenix, AZ 85005-6123	III. Service Delivery

Date (Mo./Yr):

IV. Original Supplemental

Page 2 of ____

		Service:D		Service:E		Service:F
V.	Budget Categories	Total Cost	CPIP Cost	Total Cost		Total Cost	CPIP Cost
1	Personnel
2	E.R.E.
3	Pro. & Outside Svcs.
4	Travel
5	Space
6	Equipment
7	Materials & Supplies
8	Operating Services
9	Indirect Costs
10	Subtotal Admin Cost	- 0	- 0	- 0	- 0	- 0	- 0
11	Vouchers
12	Total Costs	0.00	0.00	0.00	0.00	0.00	0.00
13	Rate

VI.	Other Information
1	Units
2	Clients
3	TANF Eligible Families Served
3a	Number of Families
4	TANF Non-Fed Expend (MOE)
16.5	Voucher Type:	CPIP Cost	CPIP Cost	CPIP Cost

CSBG

ESG-P

TANF

LIHEAP

VII. Contractor Information			VIII. Payment Information
Type or Print your Name	Title		Total Amount Requested
			- 0
Signature	Date Signed	Phone No.	Amount Paid (CPIP use only)

Transaction #	INVOICE #:	IX. ESG Expenditures
		Column A:	$
		Column B:	$
		Column C:	$
(Reserved for CPIP Use Only)

How many?

Sample

2.57 8.43 11.71 14.14 14.00 14.00 14.00 14.00 14.00 RESET CELL WIDTH WITH THESE VALUES

FW-110 (REV 4/12/10) CONTRACTOR'S INVOICE AND STATEMENT OF EXPENDITURES

	Arizona Department of Economic Security	I. Contractor Name:
	Division of Aging and Adult Services
		Community Action Human Resources Agency
	Attn: CONTRACT MANAGEMENT UNIT	II. DES Contract ID Number:	E6306014
	P.O. Box 6123 Site Code 086Z
	Phoenix, AZ 85005-6123	III. Service Delivery
Date (Mo./Yr):	XXXXXXX

IV. Original Supplemental

Page XX of XXX

		Service:A CMT		Service:-B		Service:-C
V.	Budget Categories	Total Cost	DAAS Cost	Total Cost	DAAS Cost	Total Cost	DAAS Cost
1	Personnel	xxxxxx	xxxxxx
2	E.R.E.	xxxxxx	xxxxxx
3	Pro. & Outside Svcs.
4	Travel
5	Space
6	Equipment
7	Materials & Supplies
8	Operating Services
9	Indirect Costs	xxxxxx	xxxxxx
10	Subtotal Admin Cost	xxxxxx	xxxxxx	xxxxxx	xxxxxx	xxxxxx	xxxxxx
11	Vouchers	xxxxxx	xxxxxx
12	Total Costs	xxxxxx	xxxxxx	xxxxxx	xxxxxx	xxxxxx	xxxxxx
13	Rate

VI.	Other Information
1	Units
2	Clients
3	TANF Eligible Families Served
3A	Number of Families
4	TANF Non-Fed Expend (MOE)
5	Voucher Type:	DAAS Cost	DAAS Cost	DAAS Cost

CSBG

ESG-P

TANF

LIHEAP

VII. Contractor Information					VIII. Payment Information
Prepared By:		Title			Page Total
XXX		XXX			TOTAL OF DAAS COST LINE 12
Date Prepared		Phone No.			Amount Paid (DAAS use only)
XXX		XXX
Transaction #	INVOICE #:		IX. ESG Expenditures
			Column A:	$
			Column B:	$
			Column C:	$
(Reserved for DAAS Use Only)

How many?

Instructions

COMPLETION INSTRUCTIONS

PURPOSE: To claim compensation for contracted services provided. A separate form must be submitted for each month of service.

ITEM I.	Preprinted
ITEM II.	Preprinted
ITEM III.	Enter the month and year for which the service was provided.
ITEM IV.	Please select Original or Supplemental to identify the invoice type.
	A supplemental invoice must be provided for information regarding net increase(s)/decrease(s) related to a prior month(s) billing.
	[Example: Total Cost and/or DAAS Cost amounts by Budget Categories (Admin &/or Voucher); Units reported].
	A brief memo of explanation, stating the reason for the increase or decrease, must accompany the invoice.
ITEM V.	Please select ADES Division/Program services were requested for. If selecting Other please write out name of ADES Program on next line.
ITEM VI.	Please enter the Client Name for DERS (RSA/WFTC) Division or N/A for DAAS (APS/RFP) Division.
ITEM VII.	Please enter the System of Record authorization number or PO number for DERS (RSA/WFTC) Division or N/A for DAAS (APS/RFP) Division.

SERVICES PROVIDED & UNITS
ITEM VIII.	The service names are in accrodance with the Rate Sheet.
Line 1:	Contractor's Rate in accordance with the Rate Sheet.

Units:	Report the number of Units provided. Use conventional rounding procedures: [.5 and greater = round up to next whole unit];
	[ less than .5 = round down to last whole unit].

Line 10: If using the formatted EXCEL spreadsheet provided by ADES, rates will be automatically calculated based on Rates and Units.

Monthly Activity Detail Report Attached
ITEM IX.	Complete all items.

Contractor Information
ITEM X.	Complete all items.

INVOICE SUBMITTAL: Submit your completed invoice electronically or as directed by your Contracts Unit or Section 10 of the Contract.

Attach all required reports to your invoice, including the Monthly Activity Detail.

RETENTION: Retain Copy of your Invoice for five (5) years following termination of contract or resolution of final audit, whichever is later.

IF THERE ARE QUESTIONS REGARDING COMPLETION OF THIS FORM, please contact the contact listed in Section 10 of the Contract.

Sample (2)

2.57 8.43 11.71 14.14 14.00 14.00 14.00 14.00 14.00 RESET CELL WIDTH WITH THESE VALUES

FW-110 (REV 7/2007) CONTRACTOR'S INVOICE AND STATEMENT OF EXPENDITURES

	Arizona Department of Economic Security	I. Contractor Name:
	Office of Community Partnerships
	and Innovative Practices	Community Action Human Resources Agency
	Attn: CONTRACT MANAGEMENT UNIT	II. DES Contract ID Number:	E6306014
	P.O. Box 6123 Site Code 086Z
	Phoenix, AZ 85005-6123	III. Service Delivery
Date (Mo./Yr):	XXXXXXX

IV. Original Supplemental

Page XX of XXX

		Service:D	EAP	Service:E	EAP	Service:F
V.	Budget Categories	Total Cost	CPIP Cost	Total Cost	CPIP Cost	Total Cost	CPIP Cost
1	Personnel
2	E.R.E.
3	Pro. & Outside Svcs.
4	Travel
5	Space
6	Equipment
7	Materials & Supplies
8	Operating Services
9	Indirect Costs
10	Subtotal Admin Cost
11	Vouchers
12	Total Costs	xxxxxx	xxxxxx	xxxxxx	xxxxxx	xxxxxx	xxxxxx
13	Rate	4.00		1.00

VI.	Other Information
1	Units
2	Clients
3	TANF Eligible Families Served
3A	Number of Families
4	TANF Non-Fed Expend (MOE)
5	Voucher Type:	CPIP Cost	CPIP Cost	CPIP Cost

CSBG

ESG-P

TANF

LIHEAP

VII. Contractor Information					VIII. Payment Information
Type or Print your Name		Title			Page Total
XXX		XXX			TOTAL OF CPIP COST LINE 12
Signature		Date Signed	Phone No.		Amount Paid (CPIP use only)
XXX		XXX	XXX
Transaction #	INVOICE #:		IX. ESG Expenditures
			Column A:	$
			Column B:	$
			Column C:	$
(Reserved for CPIP Use Only)

How many?

Sheet2

TANF Eligible Families Served

Yes

Invoice Type

Original

Supplemental

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File details come from the government source that posted it. Updated Oct 3, 2025.