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Harry Kim <br />Alm -or <br />Will Okabe <br />Alanaging Director <br />Barbara I Kossow <br />Deputy Alanaging Director <br />(91runt of PH (uni" <br />Office of tor,gor <br />25 Aupuni Street, suite 2603 • Halo, Hawai'i 96720 • (808) 961-8211 + Fax (808) 961-6553 <br />KONA 74-5044 Ane KeohokAlole Hwy., Bldg C . Kailua-Kona, Hawaii 96740 <br />(808) 323 4444 • Fax (808) 323-4440 <br />PAYMENT REQUEST FORM <br />OHANA ZONE — WEST HAWAII ASSESSMENT CENTERS & HOUSING (WHACH) <br />Form No. GCH OZ-WHACH-01, (0612019) <br />August 5, 2019 <br />Mr. Scott Morishige <br />Governor's Coordinator on Homelessness <br />415 South Beretania Street, Room 415 <br />Honolulu, Hawaii 96813 <br />To Whom It May Concern: <br />RE: OHANA ZONE —WEST HAWAII ASSESSMENT CENTERS & HOUSING <br />CONTRACT NO.: DHS-19-GOV-0085 <br />PAYMENT REQUEST NO.: 1 <br />hereby request payment under the above stated contract for the Ohana Zone — <br />West Hawaii Assessment Centers & Housing in the amount of ONE HUNDRED <br />TWENTY-FIVE THOUSAND DOLLARS ($125,000.00). This amount represents an <br />advanced payment for mutually agreed upon advanced program services for the <br />WHACH for the contract period from June 15, 2019 to June 14, 2022. <br />I certify that the services for which the payment is being made will be and are <br />being satisfactorily rendered and that all contractual obligations under the contract <br />identified above are being duly fulfilled. Documentation specifying the amount <br />accounting for the initial start-up costs and expenses will be submitted subsequently in <br />accordance with the contract terms. <br />1121-4t; <br />/} <br />- <br />Wil Okabe <br />Managing Director <br />128sih <br />Cou iiy of llawai`i is an equal Oppaatuniry 1M'tovidcr and V;rnpbq,�vr <br />