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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 />INSTRUC'I rcNS TO VENDOR OR 2. Fill in expenditures on the Expenditure Worksheet. This <br />CLAIMANT: 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 Certificote, I hereby certify under penalty of perjury that <br />the items and totals ljsted 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 dlscrimination 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 />claim. <br />(electronic <br />(TrrLE) <br />BY <br />u <br />Expenditure Report Form (ERF) <br />billi wal <br />YMPEP <br />19-33 Amend 2 <br />Kittitas County Public Health Dept <br />rt Period <br />Program: <br />Agreement Number: <br />Mar-21 <br />LINE ITEM DESCRIPTION AMOUNT THIS <br />INVOICE <br />Program Operations so.oo <br />TOTAL PAYMENT REQUESTED WITH THIS ERF:5o.oo <br />PREPARED BY TELEPHONE NUMBER DATE <br />FOR COUNTY FINANCE USE ONLY <br />/ENDOR NUMBER <br />FUND Code Distribution <br />qCCOUNTING APPROVAL FOR PAYMENT DATE <br />So,oo