Mailing Instructions: When completed, these forms will summarize all of your claims for payment. Your Claims Packet will include DPSS 2076B (if required). invoices, payroll verification, and copies of canceled checks attached, receipts, bank statements, sign-in sheets, daily logs, mileage logs, and other back-up documentation needed to comply with Contract/MOU. Mail Claims Packet to address shown on upper left corner of DPSS 2076A. [see method, time, and schedule/condition of payments). (Please type or print information on all DPSS Forms.) DPSS 2076A SUBRECIPIENT PAYMENT REQUEST "Remit to Name" The legal name of your agency. "Address" The remit to address used when this contract was established for your agency. All address changes must be submitted for processing prior to use. "Subrecipient Name" Business name, if different than legal name (if not leave blank). "Contract Number" Can be on the first page of your contract. "Amount Requested" Fill in the total amount and billing period you are requesting payment for. "Payment Type" Check the box and enter the dollar amount for the type(s) of payment(s) you are requesting payment for. "Any questions regarding…" Fill in the name and phone number of the person to be contacted should any questions regarding your request for payment. "Authorized Signature, and Date (Subrecipient's) Self-explanatory (required). Original Signature needed for payment. EVERYTHING BELOW THE THICK SOLID LINE IS FOR DPSS USE ONLY AND SHOULD BE LEFT BLANK. ASSURANCE OF COMPLIANCE WITH THE RIVERSIDE COUNTY DEPARTMENT OF PUBLIC SOCIAL SERVICES NONDISCRIMINATION IN STATE FEDERALLY ASSISTED PROGRAMS _______________________________________________________________ NAME OF ORGANIZATION
Mailing Instructions: When completed, these forms will summarize all of your claims for payment. Your Claims Packet will include DPSS 2076B (if required). invoices, payroll verification, and copies of canceled checks attached, receipts, bank statements, sign-in sheets, daily logs, mileage logs, and other back-up documentation needed to comply with Contract/MOU. Mail Claims Packet to address shown on upper left corner of DPSS 2076A. [see method, time, and schedule/condition of payments). (Please type or print information on all DPSS Forms.) DPSS 2076A SUBRECIPIENT PAYMENT REQUEST "Remit to Name" The legal name of your agency. "Address" The remit to address used when this contract was established for your agency. All address changes must be submitted for processing prior to use. "Subrecipient Name" Business name, if different than legal name (if not leave blank). "Contract Number" Can be on the first page of your contract. "Amount Requested" Fill in the total amount and billing period you are requesting payment for. "Payment Type" Check the box and enter the dollar amount for the type(s) of payment(s) you are requesting payment for. "Any questions regarding…" Fill in the name and phone number of the person to be contacted should any questions regarding your request for payment. "Authorized Signature, and Date (Subrecipient's) Self-explanatory (required). Original Signature needed for payment. EVERYTHING BELOW THE THICK SOLID LINE IS FOR DPSS USE ONLY AND SHOULD BE LEFT BLANK. ASSURANCE OF COMPLIANCE WITH THE RIVERSIDE COUNTY DEPARTMENT OF PUBLIC SOCIAL SERVICES NONDISCRIMINATION IN STATE FEDERALLY ASSISTED PROGRAMS _______________________________________________________________ NAME OF ORGANIZATION
dparc-530-2017-state-esg-rfp-tc-rev-2-14-17.docx