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Expenditure Report Form (ERF) <br />/l',/STRUaTION$ TO VE!NDOR OR CLAIMANT: <br />STATEMENT FOR SERVICES • Claim payment for materials, merchandise or services , Show complete detail for each item. <br />I Vrndar', c,rtlficaro. I herebv certify under penaltv of perjury that I <br />Submll lhl• ,n ,.,, I n -. ·-~! the items and totals Usted herein are proper charges for materials, merchandise I Co u nty of Walla Walla, Washington or services furnished to the County of Walla Walla and that all goods furnished <br />1 and/or services rendered have bll!!!en pro1Jlded without discrimination because of <br />' age, sex, marital status, race, creed, color, natlonal o,lgln, handicap, religion, or Department of Commu n ity Health <br />I Vietnam era or disabled veterans status and the cla/m is just, due and unpaid <br />PO Box 175 3 obligation against the Countv of Walla Walla and that I am authorized to <br />Wa lla Walla WA 99362 <br />IDl.!.tli!.10.:...Un!Ql111mi.1,0illins(ii}~2,~vallo·~alh1,~'.l!II~ <br />CLAI MANT ~ .. ,'~~: BY: <br />(!}l(l)lllll!ilKl <br />(TllUj l'Mm <br />Program; <br />Agroomon1 Number; <br />Claim Period : <br />DATE DESCRIPTION OF SERVICES AMOUNT <br />. <br />TOTAL PAYMENT REQUESTED WITH THIS ERF; $0 .00 <br />PREPARED DY I TELEPHONE NUMBER I DATE <br />I I <br />~' <,_ ,,, •1F..O/f COUNTY FIN.ANCBUSf!'ONI. Y, ''-'!~ • .: .. v~ • <br />1vi=i~~"f\J~l;II j UfJI NUMeni <br />FUND Code Dlslt/bul/on <br />~CCOUNTING APPROVAL FOR PAYMENT 'DATE I WARRANT TOTAL \Y/1.JJRAr« NUMDCR <br />$0 .00 <br />Re•I0~4 ,,,,.,._,