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Agency Use Only <br />Form State of Washington <br />A19-INVOICE VOUCHER Agency No. Loc:atIen Code <br />1A e ; ~ ,} <br />(Rev. '.t'0 <br />5/91) <br />AGENCY NAME INSTRUCTIONS TO VENDOR OR CLAIMANT: <br />Grant County Health District Submit this form to claim payment for materials, merchandise or services. Show <br />complete detail for each item . <br />1038 W Ivy Ave <br />Moses Lake, WA 98837 Vendor's Certificate: I hereby certify under penalty of perjury that the items and <br />totals listed herei n 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 />VENDOR OR CLAIMANT (Warrant is to be payable to) -(Signature) <br />By <br />-- <br />(Name, Title) (Date) <br />Month <br />1422 Year 1 Carry Over Funds 1422 Year 2 Funds <br />Camp #2 <br />Camp #1 (YR1) (YR1) Camp #1 (YR2) Camp #2 (YR2) Total <br />Salaries $ - <br />Benefits $ - <br />Goods & Services $ - <br />Indirect Costs $ - <br />Total $ -$ -$ -$ -$ - <br />Prepared by Phone# Date Agency Approval Date <br />Interagency Agreement -Kittitas Amendment#l <br />11/20/15 <br />Page 8 <br />I