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 Ilam, <br />Vendor's Certificate. 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 or <br />County of Walla Walla, Washington services furnished to the County of Walla Walla and that all goods furnished and/or <br />services rendered have been provided without discrimination because of age, sex, <br />marital status, race, creed, color, national origin, handicap, religion, or Vietnam era <br />Department of Community Health or <br />disabled veterans status and the claim is Just, due and unpaid obligation against the <br />PID Box 1753 Countyof Walla Walla and that I am authorized to authenticate and certify to said <br />claim. <br />Walla Walla, WA 99362 <br />CLWIIIIANT.; ; - BY: <br />Kittitas County Health Department (SIGN IN INK) <br />507 N. Nanum St. Suite 102 (TITLE) toAte} <br />Ellensburg WA 98926 Program: YMPEP <br />Agreement Number: #16.81 <br />Claim Period: <br />DATE <br />_ _ - _ DESCRIPTION OF SERVICES <br />AMOUNT <br />$2,000.00 <br />Completed needs assessment template provided by WWCDCH with 10th grade 2014 data <br />Implemented electronic survey provided by WWCDCH to institutions of higher learning who <br />serve the 18-20 year old population <br />$1,500.00 <br />Return completed needs assessment template to WWCDCH <br />$1,500.00 <br />_ -_ -- -- _ _ - - -- = TOTALPAYMENTREQUESTED WITH THIS ERF; <br />$5000.00 <br />PREPARED BY <br />TELEPHONE NUMBER <br />DATE <br />FOR COUNTY FINANCE USE ONLY <br />BOE NUMBER UFfI NUMdEk <br />FUND Code Distribution <br />.............. .... <br />ACCOUNTING APPROVAL FOR PAYMENT <br />iOATE <br />WARRANT TOTAL <br />$5,000.00 <br />WARRANTNUMSER <br />rrurâ–ºr] <br />