V - - a FORM GEORGI FIN1510-01 For Accounts Payable Use Only Vendor Number CHECK REQUEST FORM Use this form to arrange for payment to individuals or businesses when a Purchase Order or P-card is not required. This form must be submitted in typed format only. Vendor Information Vendor or Employee Name Date Department Name Amilia Technologies USA inc. 3/25/2025 Parks and Recreation If there is a Purchase Order issued for this expense, DO NOT USE THIS FORM. Ifs so, submit invoice with a copy of the PO. Mailing Address 1751 Rue Richardson, Suite 3.105 If payment is to a Vendor, is a W-9 on Montreal, Quebec, H3K 1G6 filei in the Purchasing Office? If No, a completed W-9 MUST be Email Address attached. Email Shervondaells@rocktalecountygagow in our Purchasing Division for a complete New Vendor Packet. Kaeadarsas. EXPENSE/ACCOUNT DETAILS Description (fori individuals, Services, Date of General Ledger Account Expense Reimbursements) Service or Amount Invoice Fund Function Account Dept. 1560556, 1562055,1563562 100 6200 523850 61 $21,996.69 1565088, 1566624, 1569711 la. 120 1571260, 1572832, 1574410 Dero 6/30124 hRu 1 n ep - am Dors netThdwde oyerwen . Da HAve ndr reckivc d L e b y BUDGETED ( V) NOT BUDGETED () Total Check Amount $21,996.69 DESCRIBE FULLY THE NATURE OF THE PAYMENT C-2023-1A Various invoice payments for Balance of Credit Card Payment fees Various invoice dates! Different months SIGNATURES/APPROVAES Dept. Designee Date Chief Financial Officer/Designee Date Th-pN 452035 4.15.25 Accounting Offiçen Date Senior Procurement Manager Date ML Ma LAne 4hyiss CHECKI HANDLING INSTRUCTIONS 5.Mail 6. Pick Up-Approval by CFO 7.5 Sendl Inter-Department Mail: (Enclose attachments if required in letter: size Available at the Finance Office Front Desk after Will be placed in mailbox after 2:00 p.m every Friday envelope) 2:00 pme every Friday Révised 1/17/25 D ahe)s Please send this form with attachments to the Dépairtmen df Finince. Each check request received Monday-Friday will be processed the'following Friday. a05-234 AMILIA Amilia Technologies USA inc. SmartRec 1751 rye Bichardson, Suite 3,105 Montréal, Québec, H3K 1G6 Invoice Involce detals AR 35 Client Rockdale County Parks & Recreatian PO Box 289 Conyers, GA 30012 Account number 0016643 Invoice number 1560556 lnvoice date Jun 30th, 2024 Payment terms Due upon receipt 23 27 S Aon a Invoicesimmary (For June 2024) BE 4RA 133 Item Description Amgunt USD Can/US credit card $2,866.13 Payment AMEX credit card $95.46 Network assessment Payment processing $55,22 Subtotal $3,016.81 Total $3,016.81 Please issue al bank transfer ora check as soon as possible. Inc case af payment by check, please note that we may apply an additional $30 feet to youra account balance, Please contact success@amila.com: to discuss alternative payment methods. Thank your for choosing Amifia! Ifyoul have any questions, don't hesitate to contact us at support@amlla.com AMILIA Amilia Technalogies USAI inc. SmartRec 1751 fue Richardson,S Suilte 3.105 Montréal, Québec, H3K: 1G6 invoice a Invoice detals - Client Rockdale County Parks & Recreation PO Box 289 Conyers, GA 30012 Acçount numper Q016643 Invoice number 1562055 Invoicè date Jul 31st, 2024 Payment terms Due upon receipt 136 naicsmnawtal July 20241 - 7 A EM Item Description Amiouit USD Can/US credit çard $2,783.94 Payment AMEX dredit card $135.65 Payment praçessing $78.76 Network assessment PCI non-compliance feé $34.95 Subtotal $3,033:30 Total $3,033.30 Please Issué a bank transfer or a check as soon as possibje. Inc case of payment by check, please notet that we may apply an: additional $30 fee to your account balance. Please contact success@amilla.com to discuss alternative payment methods. Thank you for choosing Amilia! Ify youl have any questions, don'th hesitate to contact us at support@amiia.com AMILIA Amllla Tachnologies USAI inc. SmartRec 1751 ruel Richardson,! Sulte 3.105 Montréal, Québec, H3K: 1G6 Invoice Invoice details 56 AAA Client Rockdalé County Parks & Recreation PO Box 289 Conyers, GA 30012 Account number 0016643 Invoice number 1563562 Invoice date Aug 31st, 2024 Payment terms Due upon receipt Invoice ( 105 5 5 - UMTAVPTAURBPA, M 4 Me us Item Description Amount USD Can/US credit card $2,685.42 Payment AMEX. credit card $254:47 Payment processing $72.97 Network asséssment Chargeback $25.00 PCI non-compliance fee $34.95 Subtotal $3,072.81 Total $3,072.81 Please issue al bank transfer ora check as soon as possible. Inc case of payment by check, please note that we may apply an additional $30 fee to your account balance. Please contact success@ainlla.comt to discuss alternatiyé paynjent methods. Thank you for choosing. Amillal Ifyou have any questions, don't hesitate to contact us ats support@amila.com AMILIA Amilla Technologies USA Inc, SmartRec 1751 rue Richardson,Suite: 3.105 Montréal, Québec, H3K 1G6 Invoice d fInvolce details M : - Client Rockdale County Parks & Recreation PO Box 289 Conyers, GA 30012 Account number 0016643 Invoiçe number 1565088 Invoice date Sep 30th, 2024 Payment terms Due upon receipt Involce summary ga 3 (For September 2024) % AS 7 - 876 3 N 0 - 96 Item Description Amourit USD Can/us credit card $1,652.68 Payment AMEX credit card $176.79 Payment pracessing $62.25 Network assessmept PCIn non-compllance fee $34.95 Subtotal $1,926.67 Total $1,926.67 Pleasel Issue a bank transfer or a check as soon as possible. In case of payment by check, please note that we may apply an additidnal $301 fee tos your account balance. Please contact success@amilla.com to discuss alternative payment methods. Thank you for choosing Amillal Ifyoul have any questions, don't hesitate to contact us at support@amila.com AMLLIA Amilia' Technologies USAI inç. SmartRec 1751 rue Richardson, Suite 3.105 Montréal, Québec, H3K1 1G6 Invoice Invoice detalls - - 5 Client Rockdale County Parks & Recreation PO Box 289 Conyers, GA 30012 Account numbér 0016643 Involce. numper 1566624 Invoice daté Oct 31st, 2024 Payment terms Due upon receipt B3 A Invoice summary (Fo October 2024) w AA 5 - Item Description Amount USD Can/UScredit card $1,790.39 Payment AMEX credit card $124.72 Network assessment Payment processing $19,62 PCI non-compliance fee $34.95 Subtotal $1,969.68 Total $1,969.68 Please issue a bank transfer or a check as soon as possible. In çase ofp payment by check, please note that we mayapply an additional $301 fee toy your account balance, Please contact success@amlia.com to discuss alternative payment methads. Thank you for chopsing Amilial Ifyoul have any questions, don'thesitate to contact us at support@amlia.com AMILIA Amilia Technologies USAI inc. SmartRec 1751 rue Richardson, Sulte 3.105 Montréal, Québec, H3K1 1G6 Invoice E Linvoice détalls 1 - MS 1 Client Rockdale County Parks & Recreation PO Box 289 Conyers, GA 30012 Account number 0016643 Invoice number 1569711 Invoice date Dec 31st, 2024 Payment terms Due upon receipt Invoice summary (For December 2024) Wa AE 5 Item Description Amount USD Can/US credit card $1,051.50 Payment AMEX credit card $105.38 Network assessment Payment proçessing $27,03 PCI non-compliance fee $69,90 Subtotal $1,253.81 Total $1,253.81 Please issue a barik transfer or a check as soon. as possible. In case of payment by check, pléase note that we may apply an. additional $30 fee to your açcount balance.. Please contact success@amlla.com to discuss alternative payment methads. Thanky you for choosing Amljal Ifyoul have any questions, don't hesitate to contact us at support@amlla.com AMILIA Amilia Technologies USA inc. SmartRec 1751 rue Richardson, Suite 3.105 Montréal, Québec, H3K: 1G6 Invoice Invpice detalls C LM a Client Rockdale County Parks & Recreation PO Box 289 Conyers, GA 30012 Accourt number 0016643 Invoice number 1571260 Invoice date Jan 31st, 2025 Payment terms Due upon receipt y 9RESE % 2 Invaice summary (For January 2025) a 8u Vs A Item Description Amount USD Can/US credit card $1,495.89 Payment AMEX crédit card $166.01 Payment processing $29.81 Network assessment Chargeback $25.00 PCH non-complance fee $34.95 Subtotal $1,751.66 Total $1,751.66 Please issue a bank transfer or a check ass soon as possible. Inc case of payment by check, please note that we may apply an additional $30 feet to your account balance. Please contact success@amilla.com to discuss alterative payment methods. Thank you for choosing Amilial lfyou have any questions, don't hesitate to contact us at support@amila.com AMILIA Amilla Technologles USA inc, SmartRec 1751 ruel Richardson, Sulte 3.105 Montréal, Québec, H3K: 1G6 Invoice 892 6 - hvocedetalis eSiR 35 Client Rockdale County Parks & Recreation PO Box 289 Conyers, GA 30012 Account number 0016643 Invalçer number 1572832 Involce daté Feb 28th, 2025 Payment terms Due upon reçeipt Invoice summary - (For February MS 2025) A LH B E 5s AE 2 itém Déscription Amount USD Can/us credit card $2,063,75 Payment AMEX credit càrd $186.58 Network assessment Payment processing $38.50 PCI non-compliance fee $34.95 Subtotal $2,323.78 Total $2,323.78 Please Issue a bank transfer or a check as soon as possible. In case of payment by check, please note that we may apply an additional $30 fee to your account balancé. Please contact success@amilia.com to discuss alternative payment methods. Thank you for choosing Amilial Ify youl have any questions, don't hesitate to contact us at support@amlla.com AMILIA Amilia Technologies USAI inc. SmartRec 1751 ruel Richardson, Sulte 3.105 Montréal, Québec, H3K: 1G6 Invoice Einvoice detalls 3 A 3E Client Rocklale County Parks & Recreation PO Bos 289 Conyers, GA 30012 Account number 0016643 Involce number 1574410 Invoice date Mar 31st, 2025 Payment terms Due upon receipt Invoice summary (Eorh March 2025) - - a S 3 NWMS13 Ea ME a a A Item Description Amount USD Can/US credif card $3,232.49 Payment AMEX credit card $283.43 Network assessment Payment processing $82.25 Chargeback $50,00 Subtotal $3,648.17 Total $3,648.17 Please issue a bank transfer or a chéck as soon as possible, In case of payment by check, please note that we may apply an additional. $30 fee to your account balance. Please contact success@amila.com to discuss alternative payment methods, Thank you for choosing Amilial Ify you! have any questions, don't hesitate to contact us at support@amlla.com