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Expenditure Report Form (ERF) <br />INSTRUCTIONS TO VENDOR OR CLAIMANT: <br />ST ATEM ENT FOR SERVICES -Claim payment for materials, merchandise or services Show complete detail for each item . <br />Vendor's Certificate. I hereby certify under penalty of perjury that <br />Submit this form to c.ontractor: the items and totals listed herein are proper charges for materials, merchandise <br />County of Walla Walla, Washington <br />or services furnished to the County of 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, calor, national origin, handicap, religion, or <br />Vietnam era or disabled veterans status and the claim is just, due and unpaid <br />PO Box 1753 obligation against the County of Walla Walla and that I am authorized to <br />Walla Walla WA .9936 2 <br />(:1Jl!!.i! !\>; OCHConllilolsBilling @lco.wa lla -WB lln ,w8,us <br />Ct:AIM!.INT BY: <br />(liIQN IN lNl1l <br />[I <br />(TITLE) (O/;T!;) <br />Program: <br />Agreement Number: <br />Claim Period: <br />DATE DESCRIPTION OF SERVICES AMOUNT <br />TOTAL PAYMENT REQUESTED WITH THIS ERF : $0.00 <br />PREPARED BY ITELEPHONE NUMBER I DATE <br />I I <br />FOR COUNTY FINANCE USE ONL Y <br />VEt/DOH NYmIllR U8lNUM~ <br />FUND Code Distribution <br />ACCOUNTING APPROVAL FOR PAYMENT I DATE J <br />WARRANT TOTAL WARRANT NUMBER <br />Re-IlS,id 7117/1f>