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Form <br />A19-1A <br />(Rev. 11191, <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 />VE NDOR 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 Usa Only <br />Agency Location Code <br />No. <br />INSTRUCll0NS 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 eech Item. <br />Vendor's Certificate: I hereby certify under penalty of perjury that the <br />items and total. listed herein are propar charges for materials , <br />merchandise or services furnished to the State of Washington, and that all <br />goods fuml.hlld andlor services rendered havI bean provided without <br />dl.crlmlnatlon because of agl, Bell, merltal statUI, race, crelld, color, <br />natJonal origin, handicap, religion, or Vietnam era or dl8abled veterans <br />atatua. <br />(Signature) <br />By <br />(11tI8) (Date) <br />I Agency Approval I Date <br />Youth Tobacco Interagency Agreement -Kittitas Amendment#2 <br />10/28/1 6 Page 10