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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 Wall wA 99362 <br />CLAIMANT <br />1. All invoices shall be sumbited using this Expenditure <br />Request Form as an Excel document. <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 />document. <br />STATEMENT FOR SERVICES - claim payment for materials, merchandise or seryices. show complete detail for each item. <br />vendot's Certificote. 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 />Expenditure Report Form (ERF) <br />BY: /s/ <br />(electronic <br />(TrrLE)(DArE) <br />natu re <br />I N ST R U CT rcN S T O VEN DOR O R <br />CLAIMANT: <br />YMPEP <br />19-33 Amend 2 <br />Jun-21 <br />Kittitas County Public Health Dept <br />Program: <br />Reporting Period: <br />reement Number: <br />AMOUNT THIS <br />INVOICELINE ITEM DESCRIPTION <br />So.ooProgram Operations <br />So.ooTOTAL PAYMENT REQUESTED WITH THIS ERF: <br />TELEPHONE NUMBER DATEPREPARED BY <br />FOR COUNW FINANCE USE ONLY <br />UBI NUMBER <br />FUND Code Disttibution <br />DATE <br />So.oo <br />\CCOUN]ING APPROVAL FOR PAYMENT