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Contract Template <$200,000 <br />May 2021 <br />REV: 09-22-22 VR <br />-Invoice #3 <br />a. List of CBO and County Health participants in County Promotora <br />Collaborative <br />b. List of RWC CCCS Neighborhood Action Team members <br />c. Final hard copy and digital Community Resource Handbook <br />d. List of Pilot Training participants. <br />e.Number of community members reached via the Promotora program <br />-Invoice #4 <br />a. Progress report using the GHSMC Funding Final Report template <br />describing progress on deliverables, challenges, accomplishments, <br />and Final Report on monthly convenings of Neighborhood Action Team <br />b.Final presentation for GHSMC forum <br />c.Final Pre-and post-session survey results for the Promotora training <br />and outreach <br />d.Final number of community members reached by the Promotora <br />program and referral type <br />e.List of partners and number of collaborations <br />f.Statement of systems transformation or sustainable community impact <br />achieved after project <br />7) All invoices shall include the following language and a signature: <br />Under the penalty of perjury under the laws of the State of California, I hereby certify <br />that this invoice of services complies with all terms and conditions referenced in the <br />Agreement with San Mateo County. <br />Signature: __________________________, Date: ________________________ <br />Title: ______________________________, Agency: _________________________ <br />8) Payments received are to cover all costs of the Contractor, including, but not <br />limited to, staff time, paperwork, travel, copies, and materials/equipment. <br />-No Travel and indirect expenses. Meeting cost will not exceed $1,800 for <br />the duration of the contract. <br />-Itemized receipts for travel and meetings expenses must be submitted <br />along with the monthly invoice. <br />-Example of itemized receipts would be: Restaurant receipts, parking fee <br />receipts, toll fee receipts, google mileage from/to, conference fee and etc. <br />9) County shall have the right to withhold payment if the County determines that the <br />quality or quantity of work is unacceptable. <br />ATTY/AGR.2022.201/County of San Mateo (Page 17 of 20) <br />DocuSign Envelope ID: 48103F1F-8EC3-4EF4-AA5B-D8465A300A24