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Expenditure Report Form (ERF) <br />INSTRUCTIONS TO VENDOR OR CLAIMANT: <br />STATEMENT FOR SERVICES • Claim payment for materials, merchandise or services. Show complete detail for each item. -------Vendor's Certificate. I hereby certify under penalty of perjury that <br />Submit this form ,fo Confra"1"r--the items and totals listed herein are proper charges for materials, merchandise <br />County of Walla Walla, Washington 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 a ge, sex, marital status, race, creed, color, national origin, handicap, religion, or <br />Vietnam era or disabled vet e rans 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 />Emai l IQ: :Q !:;l·l !:;Qntra.Qt~Ri11ing @ co.walln-wnll 11 .w11 .u~ <br />tU!AlMAN'r BY : <br />Kittitas County Public Health Department (SlGN IN INK) <br />(TITLE ) (DATE ) <br />Program: YMPEP <br />Agreement Number: 17-83 <br />Claim Perlod:4/1/18-6130/18 <br />DATE DESCRIPTION OF SERVICES AMOUNT <br />Salary and benefits <br />Program expenses, materials, goods and services <br />Indirect rate (personnel costs on ly) <br />TOTAL PAYMENT REQUESTED WITH THIS E~F'; $0:0 0 <br />PREPARED BY !TELEPHONE tIUM BER IOATE <br />I l <br />F()Rc;uuNTY,f(N,Yle£1JSEONLY ... <br />vlilllXlRna•'l!-'b~ UO,n~..,ER <br />FUND Code Distribution <br />ACOOCJ NTINQ APPROVAL FOR PAYMENT 1 ~~ I WARRANT TOT AL WNm>,t,/T NUMBER <br />$0.00 <br />Rev ise d 1/5/15