Laserfiche WebLink
Submit this form to Contractor: <br />County of Walla Walla, Washington <br />Department of Community Health <br />PO Box 1753 <br />Walla Walla, WA 99362 <br />CLAIMANT <br />1. All invoices shall be sumbited using this Expenditure <br />2. Fill in expenditures on the Expenditure Worksheet. This <br />ERF shall not be edited. <br />3. Do not print and sign, form is to be emailed as an Excel <br />STATEMENT FOR SERVICES - Claim payment for materials, merchandise or services. Show complete <br />vendot's Certificate. I hereby certify under penalty of perjury that <br />the items and totals listed herein are proper charges for materials, merchandise or <br />services furnished to the county of walla Walla and that all goods furnished and/or <br />services rendered have been provided without discrimination because of age, sex, <br />marital status, race, creed, color, national origin, handicap, religion, or Vietnam era or <br />disabled veterans status and the claim is just, due and unpaid obligation against the <br />County of Walla Walla and that I am authorized to authenticate and certify to said <br />clai m. <br />Expenditure Report Form (ERF) <br />Request Form as an Excel documefi- <br />BY: /sl <br />(DArE) <br />re(electronic <br />INSTRUC'ilONS TO VENDOR OR <br />CLAIMANT: <br />document. <br />4. Email to: bi <br />(TITLE) Administrator <br />YMPEP <br />19-33 Amend 2 <br />Kittitas County Public Health Dept <br />Re Period: <br />Program: <br />Agreement Number: <br />Dec-20 <br />AMOUNT THIS <br />INVOICE <br />LINE ITEM DESCRIPTION <br />So.ooProgram Operations <br />$o.ooTOTAL PAYMENT REQUESTED WITH THIS ERF <br />DATEPREPARED BY TELEPHONE NUMBER <br />FOR COUNTY FINANCF USF ONLY <br />UBI NUMBER <br />FUND Code Distribution <br />So.oo <br />dARRANT NUMBER\C'OlINTING APPROVAI FOR PAYMFNT )ATE