- 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 Evidenced Based Associates 5/5/2025 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 Attn: Nicole Janer Ifp payment is to a Vendor, is a W-9 on 2436 Steinbeck Lane filei in the Purchasing Office? Power Springs, GA 30127 If No, a completed W-9 MUST be Email Address attached. Email Shervondaeli@rocklalecountygagoy in our anergebanetwok.com Purchasing Division for a complete New Vendor Packet. Shervondaelis@rockdalerountypagoy EXPENSE/ACCOUNT DETAILS Description (for individuals, Services, Date of General Ledger Account Expense Reimbursements) Service or Amount Invoice Fund Function Account Dept. FFT Services for March 2025 4/30/025 250 2600 531769 28 $17,988.16 Ya5-8-080 AA AA FAAd * BUDGETED (x / NOT BUDGETED ( ) Total Check Amount $17,988.16 DESCRIBE FULLY THE NATURE OF THE PAYMENT FFT Services for Juvenile Court Participants SIGNATURIS/APPROVAIS Dept. Designee Date Chief Financial Officer/Designee Date 0 Yebs 5625 Acgounting Officer Date Senigr Procurement Manager Date, JAO s 5-835 1b YMalore 5/81 105 CHECK HANDLING INSTRUCTIONS 5.Mail 6. Pick Up-Approval by CFO 7.5 Send Inter- -Department Mail (Enclose attachments ifr 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 Revised 1/17/25 5-835 Please send this form with attachments to the Department of Finance. Each check request received Monday-Friday will be processed the following Friday. parass Days per Child April2025 Date Date JTS # Last Name FirstName Provider Enrolled Discharged Days SAmt County Rockdale Service FEI ChamDevo073008 Chambers Devon Grace Harbour 2/7/2025 30 $2,013.60 GarlTisa1014085 Garlington Tisahe Grace Harbour 4/1/2025 30 $2,013.60 Gilmlayd0109122 Gilmore-Sims Jayden Grace Harbour 4/1/2025 30 $2,013.60 Marskiya0826115 Marshall Kiya Grace Harbour 4/3/2025 28 $1,879.36 Montetr1107073 Montes Jeffrey Grace Harbour 1/16/2025 30 $2,013.60 Richlerr0819102 Rich Terrance Grace Harbour 1/7/2025 30 $2,013.60 SmitWil1203082 Smith William Grace Harbour 2/20/2025 30 $2,013.60 Trimisa10509092 Trimble Isaiah Grace Harbour 2/24/2025 30 $2,013.60 YOun1os11002072 Young-Poteat Josiah Grace Harbour 2/28/2025 30 $2,013.60 - - : 4 : FFT ServiceTotal! 5 268 $17,988.16 Rockdale County Total 268 $17,988.16 5/2/2025 3:58:37 PM Page 22of 24 Rockdale County Invoice for Fixed Price Contract Payments Vendor Number: Vendor # F20-1589774-001 Provider Name: Evidence Based Associates/ Empower Community Care Invoice No.: 425 Remittance Address: 3490 Piedmont Road NE Suite 304 Invoice Date: 5/5/2025 Atlanta, GA 30305 Phone No.: (724)731-0150 Fax No.: (724)731-0140 Service Area: Rockdale County Service Period : From 4/1/2025 To 4/30/2025 Type of Request ADVANCE REGULAR FINAL A B C D E F G H Total Client Balance Unit ofService Service Days/ or Annual Contract Year-To-Date Remaining Line Description Youth Served Hours Unit Costs Total Costs (D xE) Amount Expenditures Annual Contract 1 FFT 9 268 $67.12 $ 17,988.1 .16 - $ 143,294.00 S 122,091.28 $ 21,202.72 2 $ 3 $ - 4 $ 5 $ AMOUNT OWED $ 17988.16 $ 143,294.00 S 122,091.28 $ 21,202.72 certify that the above report is a true and correct reflection of this period's activities, and that the expenditures reported are made only for items which are nd directly related Project Director 5/5/2025 (315)317-6025 Signature of Provider Agency Official Title Date Phone No. FOR DEPARTMENT USE ONLY Date Invoice AUTHORIZED PERSONNEL Date CMi initials Received Date Contract Manager Signature Phone Number