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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 using this Expenditure <br />Request Form as an Excel document. <br />2. Fill in expenditures on the Expenditure Worksheet. This <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 services. Show complete <br />Vendor's Ceft ificdte. 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 />claim. <br />Expenditure Report Form (ERF) <br />ERF shall not be edited. <br />(rrLE) <br />BY <br />electronic <br />(DArE) <br />ature <br />INSTRUCTrcNS TO VENDOR OR <br />CLAIMANT: <br />YMPEP <br />19-33 Amend 2 <br />Kittitas County Public Health Dept <br />rt Period <br />Program: <br />Agreement Number: <br />Jul-20 <br />LINE ITEM DESCRIPTION AMOUNT THIS <br />INVOICE <br />Program Operations So.oo <br />TOTAL PAYMENT REQUESTED WITH THIS ERF:So.oo <br />PREPARED BY TETEPHONE NUMBER DATE <br />FOR COUNTY FINANCF USE ONLY <br />UBI NUMBER <br />FUND Code Disttibution <br />qCCOUNTING APPROVAL FOR PAYMENT OATE <br />So,oo <br />WARRANT NUMEER <br />Revised 1/5/15