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Attachment C <br />(County/City/Tribal) Jail <br />(Street Address) <br />(Address) (Phone number) <br />ail Bed Reimbursement Form <br />Offender Housing Invoice BILL TO: WA State Department of Corrections <br />(Month) 2015 Attn: Violator Desk <br />Total Amount ($00.00) PO Box 41149 <br />Olympia, WA 98504 <br />(360) 725-8620 <br />'Daily Bed Day Rate: $65.00 DOCViolatorbedbillingsCtiDOC1.WA.GOV <br />` <br />DOC # <br />DO)3 <br />DOC Sar}etron/ DOG Sanctaon <br />C'on$nement End/r�ansfer,` out <br />To d of Billed DOC <br />Total Amount Bdied to <br />,2 <br />me _ <br />Elmer <br />712012015; <br />Start datg Date <br />- Days <br />Y <br />DOC <br />$ 12.50 <br />S 1150 <br />� <br />Doe, Jane <br />plied <br />123456 <br />01/15/89 <br />Y <br />7/19/2015 <br />7/21/2015 <br />2 <br />$130.00 <br />Smith, Johnny <br />121212 <br />02/26/62 <br />7/8/2015 <br />7/20/2015 <br />12 <br />$780.00 <br />County Boarder Exchange Days: <br />Lisa <br />Smith,.Johnny <br />Jahnsen, Doe <br />121212 <br />555555 <br />1 10/31/92 <br />08/01/15 <br />08/01/15 <br />1 -1 <br />Erin <br />-$65.00 <br />TOTAL <br />N/A <br />Y <br />1 <br />$ 4,500.0Q <br />$ 2,600,00 <br />13 <br />$845.00 <br />Doe, Jane <br />123456 <br />1/15/1989 <br />712012015 <br />Gabapentin 30 MG Tab <br />3pills <br />1234561 <br />Elmer <br />712012015; <br />Tammy <br />Y <br />Y <br />$ 1.00 <br />$ 12.50 <br />S 1150 <br />plied <br />12:34 pin <br />Williams <br />- <br />' <br />Lisa <br />Smith,.Johnny <br />121212 <br />W2611962 <br />711012015 <br />St. joseph"s Hospital . <br />7 days � <br />Chest Pain <br />Erin <br />711012015) <br />Russell- <br />N/A <br />Y <br />$ - <br />$ 4,500.0Q <br />$ 2,600,00 <br />..Ragas <br />2:40 am <br />Tull <br />Jahnsen, Doe <br />555555 <br />10/31/1992 <br />8IV2015 <br />Walla Walla General <br />5weeks <br />foreign Object <br />Billie <br />811/2015,4:10 <br />Sarah <br />N/A <br />Pending <br />$ 4.00 <br />$ 3,000.00 <br />S 4,996.00 <br />Hospital <br />Removal <br />Gohat <br />pin <br />Nichols <br />State of Washington K9561 (4) Page 25 of 25 <br />Department of Corrections 158362 <br />