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Form <br />A19-1A <br />(Rev . 5191) <br />State of Washington <br />INVOICE VOUCHER <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 />Decription Amount <br />Contract <br />Goods & Services <br />Indirect Costs <br />Total <br />Prepared by Date <br />Agency Use Only <br />Agency Location Code <br />No. <br />INSTRUCTIONS TO VENDOR OR CLAIMANT: <br />P.R. or <br />Auth. No. <br />Submit this form to claim payment for materials, merchandise or services. <br />Show complete detail for each item. <br />Vendor's Certificate: I hereby certify under penalty of perjury that the <br />items and totals listed herein are proper charges for materials, <br />merchandise or services furnished to the State of Washington, and that all <br />goods furnished and/or services rendered have been provided without <br />discrimination because of age, sex, marital status, race, creed, color, <br />national or igin, handicap, religion, or Vietnam era or disabled veterans <br />status. <br />(Signature) <br />By <br />(Title) (Date) <br />I Agency Approval I Date <br />Youth Tobacco Interagency Agreement -Kittitas Amendment#l <br />11/6/15 Page 8