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Form State of Washington <br />A19- INVOICE VOUCHER <br />1ev <br />(Rev. <br />5191) <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 />Month <br />Salaries <br />Benefits <br />Goods & Services <br />Indirect Costs <br />Total <br />Prepared by <br />1422 Year 1 Car Over Funds <br />Comp #1 (YR1) <br />Comp #2 <br />(YR1) <br />Phone <br />Agency Use Only <br />Agency No. Location Code <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 <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 Year 2 Funds <br />Comp #1 (YR2) <br />Comp #2 (YR2) <br />Agency App <br />(Date) <br />Date <br />Total <br />Interagency Agreement - Kittitas Amendment#1 <br />11/2,0/13 <br />Page 8 <br />