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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 />1. All invoices shall be sumbited usins this Expenditure <br />Request Form as an Excel document. <br />INSTRUCflONS TO VENDOR OR 2. Fill in expenditures on the Expenditure Worksheet. This <br />CLAIMANT: ERF shall not be edited. <br />STATEMENT FOR SERVICES - claim payment for materials, merchandtse or seruices. show comptete detait foreach item. <br />Vendot's Certificote. I herebV cenify under penalty of perju.y 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 />electronic <br />(rrLE) <br />is to be emailed as an Excel3. Do not Drint and sipn. <br />BY: /s/ <br />Email <br />Expenditure Report Form (ERF) <br />YMPEP <br />19-33 Amend 2 <br />Kittitas County Public Health Dept <br />Re Period: <br />Program: <br />Agreement Number: <br />May-21 <br />tINE ITEM DESCRIPTION AMOUNT THIS <br />INVOICE <br />Program Operations So.oo <br />TOTAL PAYMENT REQUESTED WITH THIS ERF:So.oo <br />PREPARED BY TELEPHONE NUMBER DATE <br />FOR COUNW FINANCE USE ONLY <br />FUND Code Distribution <br />\CCOUNTING APPROVAL FOR PAYMENT DATE <br />So.oo <br />Revised 1/5/15