FORM GEORCI 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. i Vehdorntornation: Vendor or Employee Name Date Department Name Evidenced Based Associates 6/10/2025 If there is a Purchase, Orderissuedy forthis expense, - DO NOT USE THISFORMFSO SARAXENTISPA Malling Address Attn: Nicole Janer fpayment stoavendors; aW9 on 2436 Steinbeck Lane deinthe Purchasingoficel 4 Power Springs, GA 30127 NOa OPdWSMUSLA Email Address ARAIDISAR BCKRRABAAVE nenereehanctwokcom porchahgDVEonOn. complete NewVendory Packet ronondslkOodalecounpaRouA. 4 EXPENSE/ACCOUNTI DETAILS Description (for individuals, Services, Date of General Ledger Account Expense Reimbursements) Service or Amount Invoice Fund Function Account Dept. FFT Services for May 2025 5/31/2025 250 2600 531769 28 $16,377.28 ya5-8-020 BUDGETED (x ) NOT BUDGETED () ) Total Check Amount $16,377.28 DESCRIBE FULLYTHE NATUREOFTHE PAYMENT FFTS Services for. Juvenile Court Participants SGNATYRES/APPROVA5 Dept. Designee Date Chief Financial Officer/Designee Date I - Tfly wcblwa a 6ml25 Accounting Offiter Date Senior Procurement Manager Date Lhmk 612:25 M à 3 MS GHECK HANDLING INSTRUCTIONS 75 5.Mail EPICKUp-Approval by CFO 7.5 Send Inter-Department Mail (Enclose attachments if required Inl letter size Avallable at thel Finance Office Front Desk after WiP be placed in mailbox after 2:00 p.m every Friday envelope) 2:00p pm every Friday Revised 1/17/25 Please send this form with attachments to the Department of Finance. Each check request received Monday-Friday will be processed thet following Friday. 2.319 Rockdale County Imvoice for Fixed Price Contract P'ayments Vendor Number: Vendor # F20-1589774-001 Provider Name: Evidence Based Associates/ Empower Community Care Invoice No.: 525 Remittance Address: 3490 Piedmont Roadl NE Suite 304 Invoice Date: 6/9/2025 Atlanta, GA 30305 Phone No.: 1724)731-0150 FaxNo.: (724)731-0140 Service Area: Rockdale Coumty Service Period : From 5/1/2025 To 5/31/2025 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 (DxE) Amount Expenditures Annual Contract I FFT IO 244 $67.12 s 16,377.28 s 143,294.00 $ 138,468.56 S 4,825.44 2 $ 3 $ 4 $ 5 $ AMOUNT :: 3W % $ a OWED 1637728 143,294.00 $ 4,825.44 : 2 4 $ 138,468.56 i certify that the above report is a true and correct refiection ofthis period's activities, and: that the expenditures reported arei made only for items which are nd directly related Project Director 6/9/2025 (315)317-6025 Signature of Provider Agency Official Title Date Phone No. FOR DEPARFMENT USE ONLY Date Invoice AUTHORIZED PERSONNEL Date CMi initials Received Date Contract Manager Signeture Phone! Number Days per Child Date Date JTS# Last Name FirstName Provider Enrolled Discharged Days $Amt County Rockdale S : : : % : - : : s: 7 - a 08 SE - a a , A. : S. ChamDevo073008 Chambers Devon Grace Harbour 2/7/2025 5/13/2025 13 $872.56 FortDavi0203101 Fortt Davin Grace Harbour 5/23/2025 9 $604.08 GarlTisa1014085 Garlington Tisahe Grace Harbour 4/1/2025 31 $2,080.72 Gimlayd0109122 Gilmore-Sims Jayden Grace Harbour 4/1/2025 5/16/2025 16 $1,073.92 Marsklya0826115 Marshall Kiya Grace Harbour 4/3/2025 31 $2,080.72 Montleff1107073 Montes Jeffrey Grace Harbour 1/16/2025 31 $2,080.72 Richterr0819102 Rich Terrance Grace Harbour 1/7/2025 5/20/2025 20 $1,342.40 SmitWil1203082 Smith William Grace Harbour 2/20/2025 31 $2,080.72 Trimisai0509092 Trimble Isaiah Grace Harbour 2/24/2025 31 $2,080.72 Younlosi1002072 Young-Poteat Josiah Grace Harbour 2/28/2025 31 $2,080.72 Sar 3 : : - : - 20 - Service Total 16,377.28 A5 Rockdale County Total 244 $16,377.28 6/5/20257:39:12 PM Page 20of 22 Board of Commissioners Agenda Item Transmittal Form Procurement/Contract Transmittal Form GRORC Type of Contract: Single Event CC Use Only Contract #: Submission Information: Vendor Information: Contact Name: Vendor Name: Criminal Justice Coordinating Council Tamara McCombs Department: Address: 104 Marietta St., NW Suite 440 Atlanta GA 30303 Juvenile Court Project Title: Email: mixkelsonedccgagow FY 25 CJCC Juvenile Justice Incentive Grant Awar Phone #: 404-657-1959 Budgeted: Yes Contact: Stephanie Mikkelson Funding Account Number: 250-2600-531796-28 Term of Contract: July 1, 2024 June 2025 Contract Amount: $215,287 Contract Type: Services Contract Action: New Original Contract Number: Y25-8-020 Notes and Comments: The Rockdale County Juvenile Court respectfully requests approval for payment in the amount of $16,377.28 to cover Functional family Therapy (FFT) Services provided during the month of May 2025.