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Interagency Agreement - Kittitas <br />03/02/15 to Page 8 <br />Agency Use Only <br />Form State of Washington <br />A19 -1A INVOICE VOUCHER <br />(Rev. 5/91) <br />Agency Location Code P.R. or <br />NO. Auth. No. <br />AGENCY NAME <br />INSTRUCTIONS TO VENDOR OR CLAIMANT: <br />Submit this form 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 totals <br />listed herein are proper charges for materials, merchandise or services furnished to the <br />State of Washington, and that all goods furnished and/or services rendered have been <br />provided without discrimination because of age, sex, marital status, race, creed, color, <br />national origin, handicap, religion, or Vietnam era or disabled veterans status. <br />(Signature) <br />By <br />(Title) (Date) <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 />Federal ID No or Social Security No (For Reporting Personal Services Contract Payments <br />toIRS) <br />Received By Date Received <br />Date <br />Description <br />Component #1 <br />Component #2 <br />Total <br />Month: <br />Salaries <br />Benefits <br />Travel <br />Goods & Services <br />Indirect Rate: 22% of salary/benefits <br />only <br />TOTAL <br />Prepared by <br />Telephone Number <br />Date Agency Approval <br />Date <br />Interagency Agreement - Kittitas <br />03/02/15 to Page 8 <br />