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Submit this form to Contractor: <br />County of Walla Walla, Washington <br />Department of Community Health <br />PO Box L753 <br />Walla Walla, WA 99362 <br />CLAIMANT <br />Expenditure Request Form as an Excel document. <br />This ERF shall not be edited. <br />3. Do not print and sign, form is to be emailed as an <br />Excel document. <br />STATEMENT FOR SERVICES - claim payment for materials, merchandise or seryices. show complete detait for each item. <br />Vendor's Certificate, I hereby certify under penalty of perjury that <br />the items and totals listed herein are proper charges for materials, <br />merchandise or seryices furnished to the County of Walla Walla and that <br />all goods furnished and/or services rendered have been provided without <br />discrimination because of age, sex, marital status, race, creed, color, <br />national origin, handicap, religion, or Vietnam era or disabled veterans <br />status and the claim is just, due and unpaid obligation against the County <br />of Walla Walla and that I am authorized to authenticate and certify to <br />Expenditure Report Form (ERF) <br />(rrLE) <br />to <br />sumbited usins this1. All invoices shall <br />electronic si natu re <br />BY; /s/ <br />2. Fi <br />INSTRUCNONS TO VEN DOR OR <br />CLAIMANT: <br />PEP <br />19-33 Amend 2 <br />Kittitas County Public Health Dept <br />Program: <br />Agreement <br />Jan-2! <br />LINE ITEM DESCRIPTION AMOUNT THIS INVOICE <br />Program Operations So.oo <br />TOTAL PAYMENT REQUESTED WITH THIS ERF:So.oo <br />PREPARED BY TELEPHONE NUMBER DATE <br />FOR COUNTY FINANCE USE ONLY <br />VENDOR UBI NUMBER <br />FUND Code Distribution <br />ACCOUNTING APPROVAL F(DATE WARRANT <br />So.oo <br />WARRANT NUMBER <br />Revised