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Form State of Washington <br />Al 9- (; J, INVOICE VOUCHER <br />1A <br />(Rev <br />5/91) <br />AGENCY NAME <br />Grant County Health District <br />1038 W Ivy Ave <br />Moses Lake, WA 98837 <br />VENDOR OR CLAIMANT (Warrant is to be payable to) <br />I Month <br />Salaries <br />Benefits <br />Goods & Services <br />Indirect Costs <br />Total <br />Prepared by <br />1422 C mp #1 <br />PS1.1 PS1.2-1.7 <br />$ $ - <br />Phone # Date <br />Agoncy Use Only <br />Agency No. Location Code <br />INSTRUCTIONS TO VENDOR OR CLAIMANT: <br />Submit this forth to claim payment for materials, merchandise or services. Show <br />complete detail for each item. <br />Vendor's Certificate: I hereby certify under penalty of perjury that the items and <br />totals listed herein are proper charges for materials, merchandise or services <br />furnished to the State of Washington, and that all goods furnished and/or services <br />rendered have been provided without discrimination because of age, sex, marital <br />status, race, creed, color, national origin, handicap, religion, or Vietnam era or <br />disabled veterans status. <br />(Signature) <br />By <br />(Name, Title) <br />1422 C mp #2 <br />PS21.-2.5 & 2.7 <br />PS2.6 & 2.8 <br />Agency Approval <br />(Date) <br />Total <br />$ - <br />Date <br />Interagency Agreement - Kittitas Amendment #3 <br />10/13/2017 <br />Page 10 <br />