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Agency U80 Only <br />Form fj) State of Washington <br />A19· INVOICE VOUCHER Agency No. Location Code <br />1A <br />(Rev. <br />5/91) <br />AGENCY NAME INSTRUCTIONS TO VENDOR OR ClAIMANT: <br />Grant County Health District Submit this fonn to claim payment for materials, merchandise or services. Show <br />complete detail for each item. <br />1038 W Ivy Ave <br />Moses Lake, WA 98837 Vendor's Certificate: I hereby certify under penalty of perjury that the items and <br />totals listed herein are proper charges for materials, merchandise or services <br />furnished to the State of Washington, and that all goods furnished and/or services <br />rendered have been provided without discrimination because of age, sex, marital <br />status, race, creed, color, national origin, handicap, religion, or Vietnam era or <br />disabled veterans status. <br />VENDOR OR CLAIMANT (Warrant is to be payable to) <br />(Signature) <br />By <br />-- <br />(Name, Title) (Date) <br />Month <br />1422 Comp #1 1422 Comp #2 <br />PS1.1 PS1.2-1.7 PS21.-2.5 & 2.7 PS2.6 & 2.8 Total <br />Salaries $ - <br />Benefits $ - <br />Goods & Services $ - <br />Indirect Costs $ - <br />Total $ -$ -$ -$ -$ - <br />Prepared by Phone # Date Agency Approval Date <br />Interagency Agreement -Kittitas Amendm e nt #3 <br />10/13/2017 <br />Page 10 <br />I