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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 />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 services. Show complete <br />Vendor'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 CountV 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 />wa.us <br />BY: <br />(electronic <br />(rrLE) <br />u <br />Expenditure Report Form (ERF) <br />a-wal <br />I N ST RU C-N ON S TO V EN DO R O R <br />CLAIMANT: <br />PEP <br />19-33 Amend 2 <br />Kittitas County Public Health Dept <br />Program: <br />Period: <br />Number: <br />Nov-20 <br />LINE ITEM DESCRIPTION AMOUNT THIS <br />INVOICE <br />Program Operations $6,678.0e <br />TOTAL PAYMENT REQUESTED WITH THIS ERF:s6,678.09 <br />PREPARED BY TELEPHONE NUMBER DATE <br />FOR COUNTY FINANCE USE ONLY <br />UBI NUMEER <br />FUND Code Distribution <br />\CCOUNTlNG APPROVAL FOR PAYMENT DAT€ <br />So,oo <br />Revised 1/5/15