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Expenditure Report Form (ERF) <br />INSTRUCTIONS TO VENDOR OR CLAIMANT: <br />STATE M EN T FOR S E RVI C ES • 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 />ISubmlt this form to Conllac:tor: the items and totals listed herein are proper charges for materials, merchandise <br />County of Walla Walla, Washington or se rvices 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, color, 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 99362 <br />Iimnll IO! D~HCQnI[ll!<fjD!IIing@.&Q ,wtl l ln-);l'1l1l6,w:U15 <br />C"LAlrtfANT BY : <br />(SIGN IN INK) <br />(T1ll£, (D/ITE] <br />Arogram: <br />Agreoment 'Number: <br />Claim Period ; <br />DATE DESCRIPTION OF SERVICES AMOUNT <br />TOTAL PAYMENT REQUESTED WITH THIS ERF: SO .OO <br />PR~PARED BY ITELEPHONE~UMBER I DATE <br />I I <br />FOR cour!l'rYrFINAf(CffUSE"f1NI. y <br />ve .... 'o'! , ... ,.,Ut:lj IJO.'''IIMiI.ER <br />FUND Code Distribution <br />AIl(:(lUNT1Nq APPROVAL FOR PAYMENT IOATE <br />I <br />WARRANT TOTAL WAFlRJI!(1' NUMBER <br />$0,00 <br />flel"O()d 115115