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STATE OF HAWAII <br />REQUISITION & PURCHASE ORDER <br />DEPARTMENT OF HEALTH <br />EXECUTIVE OFFICE ON AGING <br />ORGANIZATION FUNCTION AND ACTIVITY <br />NOTICE TO VENDORS <br />Conditions of purchase are listed on the back side of this purchase order. Please read <br />carefully. Payments may be delayed if all steps are not followed. <br />RECEIVED SEP 0 6 2011 <br />County of Hawaii <br />Office of Aging <br />1055 Kino t ole Street, Room 101 <br />Hilo, HI 96720 <br />The State of Hawaii is an EQUAL EMPLOYMENT OPPORTUNITY and AFFIRMATIVE ACTION employer. We encourage the <br />participation of women and minorities in all phases of employment. <br />PURCHASE <br />ORDER NO. <br />*`>Zi`�'i4J n tt i <br />Date <br />ECAO 6 45, <br />6/22/11 <br />Deliver Before <br />DELIVERY ADDRESS <br />No. 1 Capitol District <br />250 South Hotel St., Suite 406 <br />Honolulu, HI 96813 -2831 <br />BILLING ADDRESS <br />same as above <br />QUAN. <br />UNIT <br />DESCRIPTION <br />UNIT PRICE <br />AMOUNT <br />► <br />OBJECT <br />CC <br />PROJ NO. <br />PH <br />ACT <br />ESTIMATED COST <br />For administrative, personnel or other operational <br />costs of HCOA to develop the Aging g and Disabilit y <br />M <br />R <br />OPT DEPT DATA <br />XX <br />Resource Center (ADRC) in co:n,ux;<ction with the <br />X <br />XX <br />XXX <br />XX <br />Ene cut ive Office OR Aging and other county area <br />agencies on aging, to meet the federally defined <br />XXXXXXXXXXXXXXXXXXXXXXXXXX'XX <br />criteria of a statewide fully functioning AD?C. <br />X <br />X <br />$50,060.00 <br />■ <br />621 <br />S <br />11 <br />376 <br />11 <br />2990 <br />_ 11.. <br />��do, <br />REQUISI 10 ER <br />586 -010 <br />TELEPHONE <br />GOODS /SERVICES RECEIVED IN GOOD ORDER AND CONDITION BY DATE <br />VOUCHER <br />NUMBER <br />AUTHENTICATED BY: <br />AUTHORIZED SIGNATURE <br />REQUISITION NO,' <br />VENDOR <br />NUMBER <br />SFX <br />XXXXXXXXXX <br />XX <br />229436 <br />05 <br />FOR DEPARTMENT USE <br />.41400 444 r /.z /i, ee A- l 9 <br />N LY <br />SFX <br />TC <br />F <br />YR <br />APP <br />D <br />OBJECT <br />CC <br />PROJ NO. <br />PH <br />ACT <br />ESTIMATED COST <br />ACTUAL COST <br />M <br />R <br />OPT DEPT DATA <br />XX <br />XXX <br />X <br />XX <br />XXX <br />XX <br />XXXX <br />XXXXXXXXXXXXXXXXXXXXXXXXXX'XX <br />XXXXXXXXXXXiXX <br />X <br />X <br />XXXXXXXXXXX <br />61 <br />621 <br />S <br />11 <br />376 <br />11 <br />2990 <br />019 <br />50,000:60 <br />COPY 1 — \s ._i',1[ O 5////,'// <br />STATE ACCOUNTING FORM C -03 <br />JULY 1, 1983 (REVISED) <br />