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Expenditure Report Form (ERF) <br />IN57RUCTIONS TO VENDOR OR CLAIMANT: <br />STATEMENT FOR SERVICES - Claim payment for materials, merchandise or services, Show complete detail for each item. <br />_ Vendor's Certlf caxe. I hereby certify under penalty of perjury that <br />It thifs bl'ELI t2lgaLralml(lie Items and totals listed herein are proper charges for mawrials, merchandise <br />County of Walla Walla, Washington or services furnished to the Countyof 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 orlgin, handicap, religion, or <br />Vietnam era or disabled veterans status and the claim is fust, due and unpaid <br />PO Box 1753 obligation against the County of Walla Walla and that I am authorized to <br />Waila Walla WA 99362 <br />�f]�(il?C4.lVRlll•W;�IA-V%'k) <br />CLAIMANT BY: <br />IF11q <br />InTLE) ti?AYEI <br />Program; <br />Agreomont Number: <br />Claim Period: <br />DATE <br />DESCRIPTION OF SERVICES <br />AMOUNT <br />TOTAL PAYMENT REQUESTED WITH THIS ERF; <br />$0.00 <br />PREPARED BY <br />TELEPHONE NUMBER <br />DATE <br />FOR COUNTY FINANCE USE ONLY <br />rr0 ER <br />umwu aen <br />FUND Code Distribution <br />ACCOUNTING APPROVAL FOR PAYMENT <br />DATE <br />WARRANT TOTAL <br />$0.00 <br />WARRANT NUMBER <br />