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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 />Request Form as an Excel document. <br />CLAIMANT: shall not be edited. <br />3. Do not print and siRn, form is to be emailed as an Excel <br />STATEMENT FOR SERVICES - claim payment for materials, merchandise or seruices. show complete detail for each item. <br />vendor's Certificqte. 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 />cla im. <br />BYt /s/ <br />(electronic s <br />(rrLE) <br />Expenditure Report Form (ERF) <br />INSTRUCTrcNS TO VENDOR OR <br />(DAIE) <br />n atu re <br />PEP <br />19-33 Amend 2 <br />Feb-21 <br />Kittitas County Public Health Dept <br />Reporti Period <br />Program: <br />Agreement Number <br />AMOUNT THIS INVOICELINE ITEM DESCRIPTION <br />Program Operations So.oo <br />So.ooTOTAL PAYMENT REQUESTED WITH THIS ERF: <br />PREPARED BY TELEPHONE NUMBER DATE <br />FOR COUNW FINANCE USE ONLY <br />UBI NUMBER/ENDOR NUMBER <br />FUND Code Distribution <br />\CCOUNTING APPROVAL FOR PAYMENT DATE <br />5o.oo