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Expenditure Report Form (ERF)
<br />INSTRUCTIONS TO VENDOR OR CLAIMANT;
<br />STATEMENT FOR SERVICES -Claim payment for materials, merchandise or services. Show complete delail for each item.
<br />I Vendor's Certi/lcate. I hereby certify under pena lty of perj ury that
<br />I-::S"'u'"'b:-' m"'I"'t""th:-i:-s:-:f:-o-=rm",,·,·""t""o""C::-o"'n""t""ra:-c""t-o"'r:--:-""~------:--.."..".,..:-. ~"""-::-.. ::-... "". ""'""=-,., .. :"'-::,-=.,.,.::"1:, ! the items and tot als listed herein are proper charges fo r materials, merchandise or
<br />~==="",-,=======,--,::,----"":;-:"";"",;,;;,,,,:,,,=,,,,:;,",-,~",,-,='-l ' services furnished to the County of Walla Walla and that all goods furnished and/or
<br />County of Walla Walia, Washington services rendered have been provided without discrimination because of age , sex,
<br />Department of Community Health marit.1 st.tus, race, creed, color, national origin, handicap, religion, or Vietnam era or
<br />disabled veterans status and the claim is just, due and unpaid obligation against the
<br />PO Box 1753 County of Walla Walla and that I am authorized to authentic.te .nd certify to said
<br />claim .
<br />Walla Walla, WA 99362 I
<br />~d~C~hb~i~ll~in~g~s~~~c~o~.wia~ll~a~'\~Va~l;la~.\~va~.~us~~~~~-:-~~~~~~~~~d ~-----------------------------------------~
<br />BY : . :~~~~~~~~~li:ililf;~t~{<~;·/~~l;~~t.t:~t~~§1¥;';{¥~~:itt~~
<br />Kittitas County Health Department ------------------~(S~IG~N~IN~IN~K)-------------------1
<br />507 N. Nanum St. Suite 102
<br />Ellensburg WA 98926 Program :
<br />(TITLE) (DATE)
<br />YMPEP
<br />DATE
<br />PREPARED BY
<br />Agreement Number: #16·81
<br />Claim Period:
<br />Completed needs assessment template provided by WWCDCH with 10th grade 2014 data $2,000.00
<br />Implemented electronic survey provided by WWCDCH to institutions of higher learning who $1 ,500 .00
<br />serve the 18-20 year old population
<br />Return completed needs assessment template to WWCDCH $1,500 .00
<br />.' .
<br />ITELEPHONE NUMBER I DATE
<br />I I
<br />.. ,' 'c. ,:: $5.000 ;00
<br />VENDOR NUMBER '" "., " UBI NUMBER ... . "
<br />,', '" " FUND Code Distribution
<br />..
<br />, ..
<br />ACCOUNTING APPROVAl FOR PAYMENT
<br />ReVised 7/17/15
<br />. :
<br />I WARRANT TOTAL
<br />$5 ,000.00
<br />.'
<br />.'
<br />WARRANT NUMBER
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