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HUMAN SERVICES AGREEMENT FOR CORONAVIRUS RELIEF FUNDING
CAG-________
THIS HUMAN SERVICES AGREEMENT, dated __________________, is by and between the City
of Renton (the “City” or “Renton”), a Washington municipal corporation, and Mother Africa
(“Agency” or “Contractor”). The City and the Agency are referred to collectively in this Agreement
as the “Parties.” Once fully executed by the Parties, this Agreement is effective as of the last date
signed by both parties.
RECITALS
WHEREAS, Governor Inslee issued Proclamation 20-25, “Stay Home, Stay Healthy,” on
March 23, 2020, which prohibited all people in Washington State from leaving their homes or
participating in social, spiritual and recreational gatherings of any kind regardless of the number
of participants, and all non-essential businesses in Washington State from conducting business,
within the limitations therein; and
WHEREAS, Governor Inslee has issued several updates to Proclamation 20-25, including
Proclamation 20-25.3 on May 4, 2020, which established an initial four-phased approach to
reopening Washington State; and
WHEREAS Governor Inslee issued Proclamation 20-25.4 on May 31, 2020, which creates
a transition from “Stay Home – Stay Healthy” to “Safe Start – Stay Healthy;” and
WHEREAS, resources are necessary to help Renton residents with rent and food
assistance; and
WHEREAS, Section 601(a) of the Social Security Act, as added by section 5001 of the
Coronavirus Aid, Relief, and Economic Security Act (“CARES Act”) (PL 116-136), established the
Coronavirus Relief Fund (the “Fund”) and appropriated $150 billion under Title V of the CARES
Act to the Fund to be used to make payments for specified uses to States and certain local
governments; and
WHEREAS, the Washington State allocation of Fund resources has been designated to
reimburse certain additional local governments in the state for specified expenditures though
contracts administered by the State Department of Commerce; and
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9/23/2020
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WHEREAS, the City entered into an Interagency Agreement (the “Interagency
Agreement”) with the Washington State Department of Commerce (“Commerce”) regarding the
Fund for the period March 1, 2020 through October 31, 2020, attached hereto as Exhibit A and
incorporated herein; and
WHEREAS, via Resolution 4411, the City Council directed City administration to establish the City
of Renton CARES Act Relief Fund Program to utilize Fund resources, and the City’s CARES Act
Relief Fund Program includes a Rental Assistance and Human Services Support Program (the
“Program”). The focus of the Program is provide rental and food assistance and other human
services support;
NOW, THEREFORE, in consideration of the recitals, which are incorporated by reference, and the
following mutual promises and covenants contained in this Agreement, the Parties mutually
agreed as follows:
1. Scope of Services: Agency agrees to provide the services as specified in Exhibit B (titled
“Scope and Schedule of Work”), which is attached and incorporated herein and may
hereinafter be referred to as the “Services.” The Services shall be performed in a manner
consistent with applicable provisions of Exhibit A and with the accepted practices for
other similar services, completed to Renton’s satisfaction within the time prescribed by
Renton, and pursuant to the direction of the Human Services Manager (“HSM”) or
designee. In the case of multiple projects, each project shall correspond to a separate
Scope of Work.
2. Term: The term of this Agreement shall be for a period commencing August 1, 2020, and
ending October 15, 2020, unless sooner terminated under the provisions hereinafter
specified.
3. Termination: Prior to the expiration of the Term, this Agreement may be terminated or
suspended immediately, with or without cause by Renton. The Agency may cancel this
Agreement only upon thirty (30) business days’ prior written notice to Renton. In the
event Renton terminates or suspends this Agreement, the Agency will be entitled to
receive compensation for any approved Services rendered prior to the termination or
suspension of this Agreement. The HSM’s determination of compensation shall be
binding and conclusive.
4. Compensation:
A. Compensation and Method of Payment. Renton shall make payments to the
Agency based on month-end billings. Renton shall pay the Agency for services
rendered within thirty days after receipt of an invoice in a form similar to Exhibit D
attached hereto and including the information called for in Exhibit C attached
hereto. The total amount to be paid shall not exceed $50,000. If the Agency’s
invoice, supporting documentation, and reports are not submitted within ninety
(90) calendar days after completion of the services, Renton shall be relieved of all
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liability for payment to the Agency of the amounts identified in the invoice or any
subsequent invoice; provided, however, Renton may elect to pay any invoice that
is not submitted on time.
B. Requirement to report potentially duplicative funding. If the recipient currently
has other active awards of funds from or through Renton, or if the recipient
receives another award during this award’s period of performance, the recipient
must determine promptly whether funds from any of those other awards have
been, are being, or are to be used (in whole or in part) for one or more of the
identical cost items for which funds are provided under this award. If so, the
recipient must promptly notify Renton in writing of the potential duplication, and,
if Renton requests must seek a budget-modification or change-of-project-scope
grant adjustment notice (GAN) to eliminate any inappropriate duplication of
funding.
5. Monitoring: Even though the Agency is an independent contractor with the authority to
control and direct the performance and details of the Services authorized under this
Agreement, the Services must meet the approval of Renton and shall be subject to
Renton’s general right of inspection to secure satisfactory completion. Renton shall
review reports to monitor compliance with the level of service required in the Scope of
Service. Renton may also review program performance periodically on-site. Should the
Agency fail to meet the minimum level of service represented by the Performance
Measures in Exhibit B, Renton reserves the right to adjust payments a specified in
Paragraph 4 (B), “Criteria for Compensation”.
6. Record Maintenance: The Agency shall maintain accounts and records, which properly
reflect all direct and indirect costs expended and Services provided in the performance of
this Agreement and retain such records for as long as may be required by applicable
Washington State records retention laws, but in any event no less than six years after the
termination of this Agreement. The Agency agrees to provide access to and copies of any
records related to this Agreement as required by the City to audit expenditures and
charges and/or to comply with the Washington State Public Records Act (Chapter 42.56
RCW). The provisions of this section shall survive the expiration or termination of this
Agreement.
7. Project Files: The Agency shall maintain files for this project containing the following
items:
A. Notice of Grant Award.
B. Motions, resolutions, or minutes documenting Board or Council actions.
C. A copy of this Agreement and all exhibits, and Scope and Schedule of Work
correspondence regarding budget revision requests.
D. Copies of all project invoice, reports and documentation submitted to Renton.
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8. Reporting Requirements: No payment will be made to the Agency until all reports
requested by Renton are fully completed and executed by the Agency and approved by
Renton. The Agency shall submit the reports specified in Exhibit B (Scope and Schedule
of Work), on the deadlines specified such exhibit..
9. Public Records Compliance: To the full extent the City determines necessary to comply
with the Washington State Public Records Act, Agency shall make a due diligent search of
all records in its possession or control relating to this Agreement and the Services,
including, but not limited to, e-mail, correspondence, notes, saved telephone messages,
recordings, photos, or drawings and provide them to the City for production. In the event
Agency believes said records need to be protected from disclosure, it may, at Agency’s
own expense, seek judicial protection. Agency shall indemnify, defend, and hold harmless
the City for all costs, including attorneys’ fees, attendant to any claim or litigation related
to a Public Records Act request for which Agency has responsive records and for which
Agency has withheld records or information contained therein, or not provided them to
the City in a timely manner. Agency shall produce for distribution any and all records
responsive to the Public Records Act request in a timely manner, unless those records are
protected by court order. The provisions of this section shall survive the expiration or
termination of this Agreement.
10. Independent Contractor Relationship:
A. The Agency is retained by the City only for the purposes and to the extent set forth
in this Agreement. The nature of the relationship between the Agency and the City
during the period of the Services shall be that of an independent contractor, not
employee. The Agency, not the City, shall have the power to control and direct the
details, manner or means of Services. Specifically, but not by means of limitation,
the Agency shall have no obligation to work any particular hours or particular
schedule, unless otherwise indicated in the Scope of Service or where scheduling of
attendance or performance is mutually arranged due to the nature of the Services.
Agency shall retain the right to designate the means of performing the Services
covered by this agreement, and the Agency shall be entitled to employ other
workers at such compensation and such other conditions as it may deem proper,
provided, however, that any contract so made by the Agency is to be paid by it
alone, and that employing such workers, it is acting individually and not as an agent
for the City.
B. The City shall not be responsible for withholding or otherwise deducting federal
income tax or Social Security or contributing to the State Industrial Insurance
Program, or otherwise assuming the duties of an employer with respect to Agency
or any employee of the Agency.
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11. Hold Harmless: The Agency agrees to release, indemnify, defend, and hold harmless the
City, elected officials, employees, officers, representatives, and volunteers from any and
all claims, demands, actions, suits, causes of action, arbitrations, mediations,
proceedings, judgments, awards, injuries, damages, liabilities, taxes, losses, fines, fees,
penalties, expenses, attorney’s or attorneys’ fees, costs, and/or litigation expenses to or
by any and all persons or entities, arising from, resulting from, or related to the negligent
acts, errors or omissions of the Agency in its performance of this Agreement or a breach
of this Agreement by Agency, except for that portion of the claims caused by the City’s
sole negligence.
Should a court of competent jurisdiction determine that this agreement is subject to RCW
4.24.115, (Validity of agreement to indemnify against liability for negligence relative to
construction, alteration, improvement, etc., of structure or improvement attached to real
estate…) then, in the event of liability for damages arising out of bodily injury to persons
or damages to property caused by or resulting from the concurrent negligence of the
Agency and the City, its officers, officials, employees and volunteers, Agency’s liability
shall be only to the extent of Agency’s negligence.
It is further specifically and expressly understood that the indemnification provided in this
Agreement constitute Agency’s waiver of immunity under the Industrial Insurance Act,
RCW Title 51, solely for the purposes of this indemnification. The Parties have mutually
negotiated and agreed to this waiver. The provisions of this section shall survive the
expiration or termination of this Agreement.
12. Gifts and Conflicts: The City’s Code of Ethics and Washington State law prohibit City
employees from soliciting, accepting, or receiving any gift, gratuity or favor from any
person, firm or corporation involved in a contract or transaction. To ensure compliance
with the City’s Code of Ethics and state law, the Agency shall not give a gift of any kind to
City employees or officials. Agency also confirms that Agency does not have a business
interest or a close family relationship with any City officer or employee who was, is, or
will be involved in selecting the Agency, negotiating or administering this Agreement, or
evaluating the Agency’s performance of the Services.
13. City of Renton Business License: The Agency shall obtain a City of Renton Business
License prior to performing any Services and maintain the business license in good
standing throughout the term of this agreement with the City. Information regarding
acquiring a city business license can be found at:
http://rentonwa.gov/business/default.aspx?id=548&mid=328. Information regarding
State business licensing requirements can be found at:
http://dor.wa.gov/content/doingbusiness/registermybusiness/
14. Insurance: Agency shall secure and maintain:
A. Commercial general liability insurance in the minimum amounts of $1,000,000 for
each occurrence/$2,000,000 aggregate for the Term of this Agreement.
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B. In the event that Services delivered pursuant to this Agreement either directly or
indirectly involve or require Professional Services, Professional Liability, Errors and
Omissions coverage shall be provided with minimum limits of $1,000,000 per
occurrence. "Professional Services", for the purpose of this section, shall mean any
Service provided by a licensed professional or Services that requires a professional
standard of care.
C. Workers’ compensation coverage, as required by the Industrial Insurance laws of
the State of Washington, shall also be secured.
D. Commercial Automobile Liability for owned, leased, hired or non-owned, leased,
hired or non-owned, with minimum limits of $1,000,000 per occurrence combined
single limit, if there will be any use of Agency’s vehicles on the City’s Premises by or
on behalf of the City, beyond normal commutes.
E. Agency shall name the City as an Additional Insured on its commercial general
liability policy on a non-contributory primary basis. The City’s insurance policies
shall not be a source for payment of any Agency liability, nor shall the maintenance
of any insurance required by this Agreement be construed to limit the liability of
Agency to the coverage provided by such insurance or otherwise limit the City’s
recourse to any remedy available at law or in equity.
F. Subject to the City’s review and acceptance, a certificate of insurance showing the
proper endorsements, shall be delivered to the City before performing the Services.
G. Agency shall provide the City with written notice of any policy cancellation, within
two (2) business days of their receipt of such notice.
15. Successors and Assigns: Neither the City nor the Agency shall assign, transfer or
encumber any rights, duties or interests accruing from this Agreement without the
written consent of the other.
16. Notices: Any notice required under this Agreement will be in writing, addressed to the
appropriate party at the address which appears below (as modified in writing from time
to time by such party), and given personally, by registered or certified mail, return receipt
requested, by facsimile or by nationally recognized overnight courier service. Time period
for notices shall be deemed to have commenced upon the date of receipt, EXCEPT
facsimile delivery will be deemed to have commenced on the first business day following
transmission. Email and telephone may be used for purposes of administering the
Agreement, but should not be used to give any formal notice required by the Agreement.
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City of Renton:
Dianne Utecht
1055 South Grady Way, Sixth Floor
Renton, WA 98057
Phone: (425) 430-6655
Dutecht@rentonwa.gov
Fax: (425) 430-6603
Agency: Mother Africa
Risho Sapano
1209 Central Avenue S., #120
Kent, WA 98032
Phone (253) 349-8811
Risho@motherafrica.org
17. Discrimination Prohibited: Except to the extent permitted by a bona fide occupational
qualification, the Agency agrees as follows:
A. Agency, and Agency’s agents, employees, representatives, and volunteers with
regard to the Services performed or to be performed under this Agreement, shall
not discriminate on the basis of race, color, sex, religion, nationality, creed, marital
status, sexual orientation or preference, age (except minimum age and retirement
provisions), honorably discharged veteran or military status, or the presence of any
sensory, mental or physical handicap, unless based upon a bona fide occupational
qualification in relationship to hiring and employment, in employment or
application for employment, the administration of the delivery of Services or any
other benefits under this Agreement, or procurement of materials or supplies.
B. The Agency will take affirmative action to insure that applicants are employed and
that employees are treated during employment without regard to their race, creed,
color, national origin, sex, age, sexual orientation, physical, sensory or mental
handicaps, or marital status. Such action shall include, but not be limited to the
following employment, upgrading, demotion or transfer, recruitment or
recruitment advertising, layoff or termination, rates of pay or other forms of
compensation and selection for training.
C. If the Agency fails to comply with any of this Agreement’s non-discrimination
provisions, the City shall have the right, at its option, to cancel the Agreement in
whole or in part.
D. The Agency is responsible to be aware of and in compliance with all federal, state
and local laws and regulations that may affect the satisfactory completion of the
project, which includes but is not limited to fair labor laws, worker's compensation,
and Title VI of the Federal Civil Rights Act of 1964, and will comply with City of
Renton Council Resolution Number 4085.
18. Miscellaneous: The parties hereby acknowledge:
A. The City is not responsible to train or provide training for Agency.
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B. Agency will not be reimbursed for job related expenses except to the extent
specifically agreed within the attached exhibits.
C. Agency shall furnish all tools and / or materials necessary to perform the Services
except to the extent specifically agreed within the attached exhibits.
D. In the event special training, licensing, or certification is required for Agency to
provide Services he / she will acquire or maintain such at his / her own expense and,
if Agency employs, sub-contracts, or otherwise assigns the responsibility to perform
the Services, said employee / sub-contractor / assignee will acquire and or maintain
such training, licensing, or certification.
E. This is a non-exclusive agreement and Agency is free to provide his / her Services to
other entities, so long as there is no interruption or interference with the provision
of Services called for in this Agreement.
F. Agency is responsible for his / her own insurance, including, but not limited to
health insurance.
G. Agency is responsible for his / her own Worker’s Compensation coverage as well as
that for any persons employed by the Agency.
19. Other Provisions:
A. Approval Authority. Each individual executing this Agreement on behalf of the City
and Agency represents and warrants that such individuals are duly authorized to
execute and deliver this Agreement on behalf of the City or Agency.
B. General Administration and Management. The City’s project manager is Dianne
Utecht. In providing Services, Agency shall coordinate with the City’s contract
manager or his/her designee.
C. Amendment and Modification. This Agreement may be amended only by an
instrument in writing, duly executed by both Parties.
D. Conflicts. In the event of any inconsistencies between Agency proposals and this
Agreement, the terms of this Agreement shall prevail. Any exhibits/attachments to
this Agreement are incorporated by reference only to the extent of the purpose for
which they are referenced within this Agreement. To the extent an Agency
prepared exhibit conflicts with the terms in the body of this Agreement or contains
terms that are extraneous to the purpose for which it is referenced, the terms in the
body of this Agreement shall prevail and the extraneous terms shall not be
incorporated herein.
E. Governing Law. This Agreement shall be made in and shall be governed by and
interpreted in accordance with the laws of the State of Washington and the City of
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Renton. Agency and all of the Agency’s employees shall perform the Services in
accordance with all applicable federal, state, county and city laws, codes and
ordinances.
F. Joint Drafting Effort. This Agreement shall be considered for all purposes as
prepared by the joint efforts of the Parties and shall not be construed against one
party or the other as a result of the preparation, substitution, submission or other
event of negotiation, drafting or execution.
G. Jurisdiction and Venue. Any lawsuit or legal action brought by any party to enforce
or interpret this Agreement or any of its terms or covenants shall be brought in the
King County Superior Court for the State of Washington at the Maleng Regional
Justice Center in Kent, King County, Washington, or its replacement or successor.
H. Severability. A court of competent jurisdiction’s determination that any provision
or part of this Agreement is illegal or unenforceable shall not cancel or invalidate
the remainder of this Agreement, which shall remain in full force and effect.
I. Sole and Entire Agreement. This Agreement contains the entire agreement of the
Parties and any representations or understandings, whether oral or written, not
incorporated are excluded.
J. Time is of the Essence. Time is of the essence of this Agreement and each and all of
its provisions in which performance is a factor. Adherence to completion dates set
forth in the description of the Services is essential to the Agency’s performance of
this Agreement.
K. Third-Party Beneficiaries. Nothing in this Agreement is intended to, nor shall be
construed to give any rights or benefits in the Agreement to anyone other than the
Parties, and all duties and responsibilities undertaken pursuant to this Agreement
will be for the sole and exclusive benefit of the Parties and no one else.
L. Assigns and Successors. The Parties each bind themselves, their partners,
successors, assigns, and legal representatives to the other party to this Agreement,
and to the partners, successors, assigns, and legal representatives of such other
party with respect to all covenants of the Agreement.
M. Waivers. All waivers shall be in writing and signed by the waiving party. Either
party’s failure to enforce any provision of this Agreement shall not be a waiver and
shall not prevent either the City or Agency from enforcing that provision or any
other provision of this Agreement in the future. Waiver of breach of any provision
of this Agreement shall not be deemed to be a waiver of any prior or subsequent
breach unless it is expressly waived in writing.
N. Counterparts. The Parties may execute this Agreement in any number of
counterparts, each of which shall constitute an original, and all of which will
together constitute this one Agreement.
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IN WITNESS WHEREOF, the Parties have voluntarily entered into this Agreement as of the date
last signed by the Parties below.
CITY OF RENTON
By:_____________________________
AGENCY
By:____________________________
Armondo Pavone
Mayor
Risho Sapano
Executive Director
_____________________________
Date
_____________________________
Date
Attest
_____________________________
Jason A. Seth
City Clerk
Approved as to Legal Form
By Renton City Attorney’s Office
_______________________________
By: Leslie Clark
Senior Assistant City Attorney
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9/23/2020 | 3:11 PM PDT
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Exhibit B - Scope and Schedule of Work 1
Exhibit B
Scope and Schedule of Work
2020 Program Services Agreement Rent and Utility Assistance
Agency: Mother Africa 2020 CARES
Funding:
Program: Rental Assistance
This funding
will provide:
Rental assistance to individuals/families
affected by COVID Total:
Effective
Date
August 1- October 30, 2020
Annual Program Outputs:
Unduplicated Renton
Residents
15
Number of Renton residents
receiving rental and/or utility
assistance
15
The Agency shall provide the approximate number of City of Renton clients with the following
services.
Services shall be provided in a manner which fully complies with all applicable federal, state
and local laws, statutes, ordinances rules and regulations, as are now in effect or may be
amended or enacted during the course of the Agreement.
Service Unit (“SU”)/Performance Measures Goals
Unduplicated City of Renton residents served 15
SU 1 # of individuals or families receiving rental assistance 13
SU 2 # of individuals or families receiving utility assistance 10
Definition of Units of Service: (Customize for each agency)
Service Unit 1: Number of households impacted by COVID-19 in need of rent assistance.
Agency shall make payments directly to the landlord. No payments shall be made directly
to households. The estimated amount of funding provided for direct rental assistance per
family/household is $3000.
Service Unit 2: Number of households impacted by COVID-19 in need of utility assistance.
Agency shall make payments directly to the utility. No payments shall be made directly to
households. The estimated amount of funding provided for utility assistance per
family/household shall not exceed $500.
$50,000
$50,000
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Exhibit B - Scope and Schedule of Work 2
Budget $50,000
Personnel/Administrative costs (NTE 10%) &
PPE supplies
$5,000
Direct Assistance to Clients $45,000
The above Services shall be provided by October 31, 2020.
ELIGIBILITY:
1. Services provided with funding under this exhibit shall be limited to residents of Renton.
2. Economic support to client is COVID-19 related, resulting from employment and/or
business interruptions due to COVID-19 –related business closures, and/or inability to
work due to COVID-19 illness of client or a family member.
3. Clients meet the applicable income guidelines. The purpose of this program is to provide
assistance to the most income vulnerable population (those with household income of
50% or below of AMI area median income (AMI)), but clients with household income of
up to 80% of AMI can qualify.
4. Assistance will not be a duplication of benefits, i.e. the cost has not or will not be paid by
another source.
INCOME GUIDELINES
2020 HUD INCOME GUIDELINES
Median Family Income = $113,300
Effective April 1, 2020
30% MEDIAN 50% MEDIAN 80% MEDIAN
FAMILY EXTREMELY LOW- MODERATE-
SIZE LOW-INCOME INCOME INCOME
1 $25,100 $41,800 $66,700
2 $28,650 $47,800 $76,200
3 $32,250 $53,750 $85,750
4 $35,800 $59,700 $95,250
5 $38,700 $64,500 $102,900
6 $41,550 $69,300 $110,500
7 $44,400 $74,050 $118,150
8 $47,300 $78,850 $125,750
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Exhibit B - Scope and Schedule of Work 3
RECORDS REQUIRED:
Records shall be maintained that provide:
1) Income information based on the 2020 HUD Income Guidelines Table.
2) Documentation that each recipient’s family income does not exceed the applicable limits.
3) Documentation that assistance will not be a duplication of benefits.
4) Records of payments to landlords/utilities include the address for which payment was
made. An example of such record is certification from a landlord that rent was due for an
address for which payment was made under this Agreement.
REPORTING:
1. Performance Measures/Demographics Report:
The Agency shall collect and retain performance measure and demographic data from the
persons served through this contract. Data shall be tracked in an ongoing manner and submitted
in a Performance Measures/Demographic Report form approved by the City (Exhibit C). Such
report shall be included with each invoice, along with any required receipts/timesheets, and be
provided to the City in accordance with the due dates below.
2. Summary of expenses:
The Agency shall submit monthly detailed receipts of funds spent under this grant.
Receipts shall document the amount spent, a detailed description of the cost and date incurred.
For administrative costs; payroll records documenting the time, a description of work performed
and support showing amount paid.
3. Eligibility:
The Agency shall collect and maintain the applicable documents required to confirm eligibility
and shall supply these documents upon request by the City.
Reporting Due Dates:
REPORT CUT OFF DATES CHECK DATES
MONTHLY INVOICES / REPORTS:
1st Reimbursement (September 15-September 30 October 8 October 15
2nd Reimbursement (October 1-October 15)) October 23 October 30
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EXHIBIT CCity of Renton, Washington2020 Human Services Performance Measures/Demographics Reporting Formfor CARES Act COVID‐19 fundingName of Agency:Reporting Period:Contract AmountGoalAmount ($) spentNo. Renton Households/ Individuals servedAmount ($) spentNo. Renton Households/ Individuals servedAmount ($) spentNo. Renton Households/ Individuals servedTOTAL Amount ($) spentTOTAL No. Renton Households/ Individuals servedRental/Utility Assistance00Food Assistance/Direct Food Purchases00Other (Specify) e.g. PPE supplies 00attach all receipts and supporting documentationTOTALS 0 0 0 0 0 0 000Demographics:Race/Ethnicity:White0Black/African American0Asian/Asian American0American Indian/Alaskan Native0Latino, Latino American, Hispanic0Native Hawaiian/Pacific Islander0Multi‐Race/Other0Unknown0TOTALS00 0 0Narrative:August 1 ‐ 31, 2020 Sept. 1 ‐ Sept. 30, 2020 TOTALSOctober 1‐October 15, 2020DocuSign Envelope ID: C1DD96AF-4D6A-408B-A696-5B85D6644F92
EXHIBIT D
Billing Voucher
To: Dianne Utecht
City of Renton
1055 South Grady Way, 6th Floor
Renton, Washington 98057
Phone: (425) 430-6655
Facsimile: (425) 430-6603
Contractor: ______________________________ Telephone: ____________________
Mailing Address: _________________________________________________________
Specific Program: _________________________________________________________
Contract period: Reporting Period:
Amount requested this invoice: $_____________________
Invoice Number: ____________________ Date of Invoice _______________________
__________________________________
Authorized signature
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BUDGET SUMMARY:
Total contract amount $______________
Previous payments $______________
Current request $______________
Total requested this
contract to date $______________
Balance remaining $______________
Note: The Contractor should use its invoice form. If the invoice does not include the Budget
Summary information shown above, then this form should be included with the Contractor’s
invoice.
DocuSign Envelope ID: C1DD96AF-4D6A-408B-A696-5B85D6644F92