Laserfiche WebLink
Expenditure Report Form (ERF) <br />INSTRUCTIONS TO VENDOR OR CLAIMANT. <br />STATEMENT FOR SERVICES- Claim payment for materials, merchandise or services. Show complete detail for each item. <br />Vendor's CertiJlcate. I hereby certify under penalty of perjury that <br />Submit this form to Contractor: the items and totals listed herein are proper charges for materials, merchandise <br />or services furnished to the County of Walla Walla and that all goods furnished <br />County of Walla Walla, Washington and/or services rendered have been provided without discrimination because of <br />Department of Community Health age, sex, marital status, race, creed, color, national origin, handicap, religion, or <br />Vietnam era or disabled veterans status and the claim is just, due and unpaid <br />PO Box 1753 obligation against the County of Walla Walla and that I am authorized to <br />Walla Walla WA 99362 <br />Emnil to: DCHContia •ts$illin a c walia-walla.wa.us <br />CLAIMANT <br />BY: <br />(SIGN IN tNK) <br />(TITLE) IRATE) <br />Program- <br />rogram:Agreement Number: <br />Agreement <br />Claim Period: <br />DATE <br />DESCRIPTION OF <br />SERVICES <br />AMOUNT <br />TOTAL PAYMENT REQUESTED WITH THIS ERF: <br />$0.00 <br />PREPARED BY <br />TELEPHONE NUMBER :OATE <br />FOR COUNTY FINANCE USE ONLY <br />VENDOR NUMBER <br />U6I NUMBEk <br />FUND Code Distribution <br />ACCOUNTING APPROVAL FOR PAYMENT <br />DATE <br />WARRANT TOTAL JVW <br />RANT N01ui?RR <br />KAVMW 011710 <br />