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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 Certificate. I hereby certify under penalty of perjury that <br />§WbMit this formContractor: the items and totals listed herein are proper charges for materials, merchandise <br />County of Walla Walla, Washington or services furnished to the County of Walla Walla and that all goods furnished <br />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 I <br />Walla Walla WA 99362 <br />Email to: DCF1CantraClcL3iflitlg[+�1cc5.,ualia-walia.wa.us <br />CLAIMANT BY: <br />(SIGN IN INK) <br />(TITLE) ;DATE} <br />Program: <br />Agreement Number: <br />Claim Period: <br />DATE <br />DESCRIPTION OF SERVICES <br />AMOUNT <br />TOTAL PAYMENT REQUESTED WITH THIS ERF: <br />$0.40 <br />PREPARED BYTELEPHONE <br />NUMBER <br />JDATE <br />FOR COUNTY FINANCE USE ONLY <br />VENDOR NUMBER T <br />I J131 NUMB EA <br />FUND Code Distribution <br />ACCO4NFNYG APPROVAL FOR PAYMENT OAFL• <br />WARRANT TOTAL <br />'NARRAt+T NUMBER <br />