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8 WASHINGTON STATE l DEPARTMENT OF COMMERCE '!. -.... AGENCY NUMBER lOIS PROJ ECT IlUl4B£fI C~Untt'uu=-Contract Number <br />1030 17 -62210-008 A19 VOUCHER DISTRIBUTION <br />AGENCY NAME INSTRUCTION TO VENDOR OR CLAIMANT: <br />DEPARTMENT OF COMMERCE Submit this form to claim payment for materials, merchandise or services. <br />ATTN: CDBG Show complete detail for each item. <br />POBOX 42525 <br />OLYMPIA, W A 98504-2525 Vendor's Certificate: I hereby certify under perjury that the items and totals listed herein are <br />proper charges for materials, merchandise or services furnished to the State of Washington, <br />VENDOR OR CLAIMANT (Warrant is to be payable to:) <br />and that all goods furnished andlor services rendered have been provided without <br />discrimination because of age, sex, marital status, race, creed, color, national origin, <br />handicap, religion or Vietnam era or disabled veterans status. <br />KITTITAS COUNTY By: <br />20S W STH ST STE lOS (SIGN IN BLUE INK)' <br />ELLENSBURG, W A 98926-2891 <br />rrrnpORT IN G PERIOD ; <br />(TITLE) (DATE) <br />Description QUANTITY AMOUNT <br />PREVIOUSLY AMOUNT REMAINING <br />BUDGET REQUESTED THIS INVOICE BALANCE <br />7574 05 Public Services 81,003.00 $81,003.00 <br />$0.00 <br />$0.00 <br />7575 21A General Admin 3,500.00 $3,500.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />TOTAL PAYMENT REQUEST $84,503.00 $0.00 0.00 $84,503.00 <br />Everything below this line is for Dept of Commerce <br />fED TAX 10' PROGRAM APPROVAL P ATE <br />DOC DATE rURRENT DOC. NO. REFERENCE DOC NO. VENDOR NUMBER <br />SWV001 0475-00 <br />iACCOUNTNO . ASD NUMBER 'vENDOR MESSAGE <br />33272 CDBG Pymt# <br />M SUB <br />TRANS 0 MASTER SUB SUB GL ACCT SUBSID INVOICE <br />CODE 0 INDEX OBJ OBJ AMOUNT NUMBER <br />62270320 NZ 5152 17-62210-008 <br />SIGNATURE OF ACCOUNTING PREPARER FOR PAYMENT DATE WARRANT TOTAL <br />f.'.CCOUNTlNG APPROVAL FOR PAYMENT <br />DAta