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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 />IN STRU CTIONS TO VEN DOROR <br />cLAtMANi: ERt shall no! be edited. <br />-" - 3. Do not print and sign, form is to be emailed as an Excel <br />STATE M E NT FOR S E RVICES - claim payment for materials, merchandise or seruices. show complete detail for each item, <br />vendor's Certificote, I herebv 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 />document. <br />e lectron ic <br />(TrrLE) <br />BY: <br />U <br />Expenditure Report Form (ERF) <br />YMPEP <br />19-33 Amend 2 <br />Kittitas County Public Health Dept <br />Period: <br />Program: <br />Agreement Number: <br />Oct-20 <br />LINE ITEM DESCRIPTION <br />AMOUNT THIS <br />INVOICE <br />So.ooProgram Operations <br />TOTAL PAYMENT REQUESTED WITH THIS ERF:So.oo <br />DATEPREPARED BY TELEPHONE NUMBER <br />FOR COUNW FINANCE USE ONLY <br />UBI NUMBER <br />FUND Code Distribution <br />DATE <br />So.oo <br />ACCOUNTING APPROVAL FOR PAYMENT