HomeMy WebLinkAboutGrant Related - BOCC (003)GXRANT COUNTY -
BOARD OF COUNTY COMMISSIONERS
1LL--il_l�J
To: Board of County Commissioners
Janice Flynn, Administrative Services Coordinator
Dew -ft: December 27, 2022
Re: Authorization for Release of BOCC Approved Funds, Dept of Commerce,
CHG Grant #22-46108-10. Hotel Leasing Amendment, Reimbursement #11,
Renew, Request #4
Renew has requested reimbursement for the above -referenced grant, per the contracted
guidelines in the amount of $594.31 for November 2022 expenses. The invoice and
supporting documentation are attached for review.
I am requesting the release of funds for payment to Renew in the amount of 594.31.
Thank you.
DEC 2 7 2022
I
ren w
Orfait k5ehmforpt fiedkWO Wt-41mss
Project # RGCHB1277
Hotel Leasing Grant
CONTRACT # 22-46108-10
Date w Account staff
Nov -22 108.150.00.0Q00.564.00'. 1100 32.24
108-150,00.0000.5,64,00.2100 3.35
108.150.00.0000.564.00.2200 2,32
108-150.00.0000.564.00.2300 8.81
108.150.00.0000,.564.00.2301 0.05
108.150.00-0000-564.00.2400 0.10
108.150.00,0000.564.00.2599 -
---- ---------- -------------
Salary, & Benefits 46.87
wax
108, 150,000.0000.5 6 1 .00. 502
152.05*
108.150,00,0000-564.00.4502
77.27 *f.
108.150.00,0000.564.00.4502
187.34,/
108.150.00,0000.564-00-4502
86.76/
Tota'f Operating Exp 503.42
Total SALARY/BENEFITS-0
5,50iv29
ADMIN 8%
44.02
-Ttp §4
sent
.... . ... ..... . ........ ........
Grantee Namei-. Grant County Lead Grantee Ust Sufi Grantee Names Below
Report Month/Year: 11/22 Grant County
Rpnp
Total
Admin
0,00
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. . $0.00
y
$0.00
lt.N.m„A,.,•_"�°•t!fi.i.•.+�F .'MlestNv�. ArS zv F!.a'•aY,S.. 1'&.�Q �1 i.bt:i
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��Hqr �pdo,, r,.r[. McwI-
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$46.87
V1]�; 503.42
•:� Jh•3i.�;'.r.i 'rr vR t! .�'.� "rl��w r•/}:--�S1Y l�
�..
1 503.x•2
2 ..1. IT•_ 1` i •:...,r y �- �7 i t�N � fit' • fi y „i: 'i '
i�fi} certRapid;Re H+�uS�n t}7 , : r
$0,00
Invoice Total
$594.31-
Grantee Name: Grant County Lead Grantee List Sub Grantee Names Below
Report Month/Year 2022 Grant County
n I if-w-rn-
tHG-Other knUFac Supp Ce -ase A HOIWn
Costs:,
CNG -Rent Fac.support/Lease- Costs , 00
tis Wwo-m-g-, No W-4 Wan -
Y I?N'.
bd
OWCH�!',Oth erl.kek/Fid.
Supp/Liase� -Mbuig 4�"
"M
IRV
1,2510,41 � WON R �� UN - i I
H E
WK
�Ws
It ... --, . g;--" 0 0 fie
IN "I
�2 wwW
AX
�5: 1141NI!,
$=0 $1,500.00
SO -00 $2,500.00
H $10,000.00
Q Leasing
$O.00
$0.00
$14,000.00
May -22 Jure -22 Jul -22 Aug -22 Sep -22 Oct -22
$0.00 $0.00 �O.Oo $0.00
$63.30 $128.69 $0.00 $0.00 $0.00
$270.22 $208.07 $452.55 $0.00 $0.00 $O.00
Invoice Tota $270.22 $271.37 $581.24 $0.00 $0.00 $0.00
Nov -,22
TOTS LOF
BALANCE -
REMAINING
$0.00
SO.00
$0,00
$0.00
$0,00
0.00
$0.00
$0.00
.$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
S0'00
$0.00
MOO
$0.00
$0.00
$o=
$0,00
Om
SO.00
$0.00
MOO
$0.00
$44.02
$44,02
$1,455.98
$46.87
$2.38.86
$2,2,61.14
$503.42
$2,434.26
$8,565,74
$0.00
$0.00
$594.31 $1,717-14 $12'282-86
gg
L�71-
I u I En
0
,olw r e LU
Nov -22
w- e.
BAR. -Acct., TOTAL EXPENSES GP LEDGER Departing
108.150.00.0000.564.00-01100
SALARY-
$
32.24
108.150-00.0000.564.00.2100
Retirement
$
3.35
1000.150.00.0000.564.00.2200
ssi
$
2.32
108i150.00.0000.564.00,2300
Medical
$
8.81
108.150.00.0000-564.00.2301
FM LA.
$
0.05
108.150.00.0000.564.00.2400
Ll
$
0.10
108.150.00.0000.564.00.2599
Employment
$
-
$
46.87
AV
Woo,
108.150.00.0000.564.00.4502
12532854- 11/05 &,6/2022 H MIS # 02 D3 EOA4A.52.05
22 -DeC 2 NIGHTS 11/7/2022
108.150.00.0000.564.00.4502
1253285411/08/2022 HMIS# 02D3EOA4A.
77.27 00 22 -Dec J. NIGHT 11/90/20-2
108.150-00-0000.564.00.4502
1254330111/21 &22/2022 HM1S#0945107F5
$
187-34 22 -Dec 2- NIGHTS 11/2.3/202--)
108.150.00,0000.564.00.4502
1254130411/01/2022 HIVIIS #lC872E5BD
$
86.76% 22-Decl NIGHT 11/2/2-022
503.42
NG
TUL
DONE
Admin 8% $ 44.02.
TOO` "'Wit
1PP# Pay Sou rco Salary
06
.www
BEHAVIORS j-%-j-JT
JOUI�NAL ENTRIES
11/1/2022
Salaries- Benofits G - Hotol.: Leasing
DEBIT CREDIT
108.150.O0.O00O.564.44.1100
$82.24•
108.15O.00.00OO.5 4.44.1201
$0.00
108.15O.00,0000.5O4.44.1202
$0.00
To& 1'.50�l%.'O'G-.00OO.-*'564-44.-121-,00.-
$3.35
564-.44''
$2,,,32
108.150.00.0000.56 .44. 01
05
108.150.00.0000.564A4.2400
108.15O.00.00OO.564.44.25OO0,
Oa0O
.. �rl,�.,�'�i
$32,62
108.150.00.0000.564.44.1 01
$0.00
108.15O.0O.00OO.564. 4.1202
$0.00
y
0
. �00000:Oo0$3.35
0�o,00�.►aof r$2.32
0 . •Y V a �r)�AO,o O���w/\V �t 1�.��FM �.,F. .,.. ... vi «.i ... ... ' _tea....- �. .,...�, .. .. .� -
$0.05
$0.10
$0.00
.9dadMIL
coop
MOTEL 6 - MOSES LAKE
AC 2M
2822 DrIggs Drive, Moses Lake 98837 USA fY Boom Number: 13()
5097660260
M64365bo@6franchise.com
Receipt
Card Type VISA
Masked Card Number )D(X)=XXXXXXX1473
Entry Mode Chip Read
Approval Code 005781
Mode.: Issuer
Transaction Type: Sale
Termwal ID: 2541265001
I agree to pay above total amount according to card issuer agreernent,
(Merchant agreement Iff Credit Voucher)
Retain this copy,for your records.
Rummage= Elm=
MERCHANT COPY / CUSTOMER COPY
MOTEL 6 - AMES LAKE
2822 Driggs Drive, Moses Lake 98837 USA
5097660260
m64365bo@6frandh!se.corn
Receipt
Card Type VISA
.Vlas-14--ed Card NumberV,,,(xxxnxm, xx1473
rk-, . Pdry Mode Chip Read
Approval Code 008848
Mode: Issuer
Transaction Type: Sale
Terminal ID: 2541265001
2
022
I agree to pay above total amount according to card issuer agreement.
(Merchant agreement if Credit, Voucher)
Retain thi's copy for your records.
MR CHANT COPY I C U STO M F A N1 PY
Confirmation No
4365ADS9.1 I
Guest Name
ORIS CRISIS
Transaction Type
CREDIT
status
AP QV- F- P,
Total Amount
A10
AOOOOO00031GIQ
TVR
8000008000
JA D
0601OA03AOAOOO
T81
6800
I agree to pay above total amount according to card issuer agreement.
(Merchant agreement if Credit, Voucher)
Retain thi's copy for your records.
MR CHANT COPY I C U STO M F A N1 PY
'00t Washlnc;�Lon Slate.
41 to OW Dl -ar-r ep,-,-
Coeni. of xmiej-vel
14
October 2022
Cornsodidated 1-11-owneless Grant
Self-Declarat'll'arn Form
Complete this form to document housing, status or inco-me, when applicable.
,,KHomelessness — In the narrative include information about household's primary nighttime residence (where they sleep the
maj-or1ty of the time) and if exiting a system of care narrative must also include information onhomelessness prior to
system of care entry.
If fleeing violence, indicate in the narrative "fleeing violence," No additional information is required,
EJ At Risk of Homelessness — Refer to Verification of Household Eligibility and Income Recertification Form for information
that needs to be included in, narrative based on housing situation.
Chronic Homelessness— Client must attest to chronic homelessness. *In addition, the case manager must provide written
documentation othe living situation and durationlfrequency, and the steps taken to obtain the standard evidence
f
allowable for chronic homelessness. This additional documentation must be in the client file.
El income — in the narrative include details on source of income, income amount, and frequency of income. In addition, case
manager r, iust document attempts to! ob-tclin written and verbal verification. This additional documentationmust be. in the
client file.
No Income — Indicate in the narrative no income."
obtain signature at first in-person meeting with client.
Chronic Homelessness* (see additional documentation required from case manager above)
Client Attestation
have experienced being homeless for the last 12 months in which I lived in
a place not meant for human habitation or in an emergency shelter, or on at least four separate occasions in the last
three years, I was homeless for a total of at least 12 months.
Client Signature,
Case Manager Signature
GRANT COUNTY AUDITOR
GRANT COUNTY, WASHINGTON
Z
40
AFFIDAVIT OF LOST RECEIPT
Name De artment Receipt Date
TYGU' i1UVlf-� Cl✓tS1S -� li � z� 2z �
Name of Vendor
Description of Expense:
0- ld V.
For of Payment
13 Cash
I
Aflcation
Vendor's Address Vendor's Telephone Number
11L� M1,10-AMCP, WA �1 1 6---zC9-- 099-- OZ10
��)�i r 1ti�z�
Total Cost
IJ
El Check �R County Credit Card 0 Personal Credit Card
(Attach copy of cleared check) (Attach copy of CC Stint - redacted)
While on official Grant County business I incurred the expense described above. I have lost, misplaced or did not
receive the receipt documenting payment. I am submitting this affidavit in lieu of the missing receipt.
I certify under penalty of perjury that this is a true and correct claim necessary expenses incurred by me while on
official Grant County business and that no payment has been received by me on account thereof and that I have not
previously requested, nor will I again request, reimbursement for these expenses.
Ep ee Signature Date
Elected Official, Department Head or Designee Name
INJ t X.
Ele,ledd official, Department Head or Designee Signature Date
T1 form may not be used for the following (since a duplicate receipt may be obtained for these expense):
1.',xvirline flight receipts
2. Car rentals receipts
I Lodging receipts
4. Registration receipts
Washbigton. State,
Department of'
C67
October 2022
Consolidated Homeless Grant
Self -Declaration Form
Complete this, form: to: document h-ousing status or 'income, when applicable.
/Homeless.n:ess — In the narrative Include *Infbr m.a.-ition about household's primary nighttime residence (where they steep. the
majority of -the timej and, if exiting a system of care narrative must also Include Ifformatilon on homelessness- prior to
system of care entry.
If fleeing violence, indicate in the narrative "fleeing violence." No additional information is required,
L] At Risk of Homelessness — Refer to Verificatlan of Household Eligibility orad Income Recertification Forra for information
that needs to be included in narrative based on housing situation,
Chronic Homelessness — Client must, attest to chronic homelessness. *In addition, the case manager must-proWde written
documentation of the living situation and d-uration1frequency, and Me steps taken to obtain the standard evidence
allowable for chronic homelessness. This additional documentation must be in the client file.
Income — In the narrative include details on source of Income, income amount, and frequency of income. In addition, case
managcr must diacunleat attempts to obtain vvi-Itten and varbal verification, T171s, additloilal docurnentation must be in the
client file.
M No income — Indicate in the narrative "no income,"
Hliill
0, q
iClieiot Identifl,
196rq
PA
SNIVI
CA v
A
Ard 0c) lov) 0110Md
AAA
V��■■�
-116,4Signat Lire
*If Intake is conducted remotely and client signoture cannoi
obtain §Ignaturc at first In-person meeting with client,
Immediately obtained, case manager should n&ate client' narrative above and
Chronic Homelessness* tqPP addit;nnni dnr1jMPnMfh1n romdrod frnm riwa rvhtinil
.it 1 77M-7.7 I
A t V,
on rv:' Iv.
have experienced being homeless for the last 12 months in which I lived in
a place not meant for human habitation or in an emergency shelter, or on at least four separate occaslons in the last
three years, I was homeless for a total of at least 12 months.
ie fit -S,
."CH igna re,,.::
.e ,
S[gna1Lire-,;-'-'-
,J,1,.
1
1. f 46. WIG 3. 221:4{ 2PAGE I'M 2
1d"e
GRIS CRISIS. J01
GRANT COUNTY
1
W, W-Shington.'"Prust Elank'-�zt--",-',
T 0 40 DOW CM8, 01AC1 1,16
Account t4umber -"V1-SA,- Page I of 2
XXXX �XYXK � -) 4(X X, -1473
Post Dat
Ti
leference
T'ran5actlons
Description
Amount
11/04
5
8I vt:f,
A 1 1
2420429N304OGMSFG
F11-AbusUS 122-2237.631 CA
Account Information
11/06
11103
AccOLInt Summary
SAGE N SAND MOTEL MOSES U-kKE WA
statement closing Date
12J0,2/2022
$20t000.00
11/06
Pres Balance
lhm
Payments and Credits
4,f C}
$0.00
Credit Limit
Available Credit
$1201000 -OG
+f4inance Charge(net)
$0.00
Cash Credit Llmft
$0.0a
$.0.00
1/06
Purchas:E,.s
+ Cash Advances
$0.00
$0.00
Available Cash
'1 1/10
11/09
+ Other Char es
$0.00.
$77.27
11/16
11115
New Balance
$0.00
$77460
11/16
Paymen't, Information
244450'ONGBLLDHPBJ
WIVI SUPERCENTER #2007 MOSES LAKE WA
Payment Due, Date: 1.2127/2022
11/20
Mi-nirnurn Pay . ment Due: $0.00
.24316,Q5NJFYWKFWJY
New Balance: $0.00
Post Dat
Ti
leference
T'ran5actlons
Description
Amount
11/04
11/02
2420429N304OGMSFG
F11-AbusUS 122-2237.631 CA
11/06
11103
2443106N4014008L
SAGE N SAND MOTEL MOSES U-kKE WA
$71,70.
11/07
11/06
2403454N600LQT37D
76 - MOSES LAKE FUEL STOpt.40SES LAKE WA
$32.00
11/0711.106
24034 54N600LQT375
76 - M08ES LAKE FUEL STOPIVIOSES LAKE tNA
$32.00
0
1117
1/06
247170551612
-QT.L
$152.05
'1 1/10
11/09
2471705N9517PXP4T
:U0
$77.27
11/16
11115
2424o52NG05K39K6F
WA DEPT OF HEALTH HSQA 360-236-4508 WA
$77460
11/16
11115
244450'ONGBLLDHPBJ
WIVI SUPERCENTER #2007 MOSES LAKE WA
$31.89
11/20
fl/17
.24316,Q5NJFYWKFWJY
SHELL OIL 12498046QO3, MOSES LAKE VIA
R1 '0VrM.A
11/27
12102
12/02
00000000000000NIPC
TOTAL PURCHASES $73919
TOTAL $739.79
TOTAL FEES FOR THIS PERJW
TOTAL INTEREST rOR THIS PERIOD
TOTAL'*FINANCE CHARGE"' BILLED IN 2022 $0.00
Remit Payment to;
WASHINGTON TRUST BANK
P0 E30X 2f27 spoKAN5, �j`tA 99210-2127
WASHINGTON TRUST BANK
PO BOX 2127
SPOKANE, WA 59210-2127
Please include your account
number on your check.
Nevi address, phone number or a -mall?
Check the TIQX to the left aind print chaflgss oil b.ick.
WASHINGTON TRUST BANK
P0 BOX 2127
SPOKANEt VIA 99210-2127
Mail Inquiries To., IL
P.O. BOX 2127 SPOKANE, VVA99210-21 2:7
We appreciate your business!
Account Number
New Balance
Minimum Payment Due
�A'
(WO
Cali Customer Service: 800-788-4578
Lost or Stolen Card; 600-788-4578
XXXX-XXXX-XXXX-1473
$0,00
NONE
Amount
Enclosed
ORIS CRISIS
GRANT COUNTY
ATTN MICHELE JADERLUND
PO BOX 37
EPHRATA 11AIA 98823-0037
000000000000000041295700310914737
Payment Due Date
December
8 M T W T F 6
I I 1 1 2 3
4 15 6 17 8 9 10
11 112.13114 15 16 J7
18 1 11 22123 21l
X8293031
Date
Tue, Nov 012022
Tue, Nov Of 2022
Tue, Nov 012022
Tue, Nov 012022
Tue., Nov 012022
Tue, Nov 012022
lax e tckk elf,
466 Melva Ln
Moses Lake. WA 98837
Phone'. +1 ('509) 765-86,36
Room: Account For:
A,
Joan Lepper
IN
TAX INVOICE
Folio #61 747
Tue, Nov 15,2022
Room 107
Check-in - Tue, Nov 01, 2022
L
Check-ouL: Wed, Nov 02, 2022
Description
Visa
trig Room
Room
City Tax
Hotel Motel Tax
State Sales Tax
let ee
I \
$65.00
$1.24
$1.30
$4.22
$15.OD
Total $0.00
IJ
Page I of 1
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Co -re solidated Homeless. Grant.- - .
Third Party Verbal Verificatton, Form; - .
Complete this form, to document housing� status or income, when. applicable.
Homelessness — In the narrative include detaills of the phone call to the temporary housing provider verifying.
applicant's temporary housing or system: of care representative verify -Ing applicant isexiting and was previously
homeless,
6fl'c' atoni-
At Risk of Homelessness — In the narrative include details of the phone call' to the relevant party. Refer to Ven -
of Household Eligibility and Income Recertification Form for specific information to include and who to contact.
Chronic Homelessness — In the norrative include details of where they Were living and specific months..
Earned income In the narrative, include name.,of employer, pay amount and frequency, average hours wo-rked per
week, amount of any additional compensation,
Other income — In the narrative include name of income source., income amount, and frequency of income.
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