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Attachment 3 <br />STATE FORM A-99: INVOICE VOUCHER <br />FORM STATE OF WASHINGTON <br />A79.7A <br />INVOICE VOUCHER <br />AGENCY NAME <br />Department of Archaeology & Historic Preservation <br />1063 S Capitol Way Suite ID6 <br />PO Box 48343 <br />Olympia, WA 985048343 <br />ATTN: <br />VENDOR OR CLAIMANT warrant Is to be payable to <br />Total: <br />AGENCY USE ONLY <br />AGENCY NO. CONTRACT NO. OR GA AUTM. NO. <br />103 <br />INSTRUCT/ONS TO VENDOR OR C!A/MANT: <br />In the absence ofa detailed invoice, submit this form to claim pnvntent far <br />materials, merchandise orsenices. Show complete detail for each item. <br />Vendor's Certificate: <br />I hereby certify under penalty of perjury that the items and totals listed herein <br />.re proper charges for mmcriak, mcrcbamlise or services fumishod m he <br />Sluts of Washington, and that all gored, fumichd and/or xrrices raiJcrd hit, <br />been pmrided withein discrimination bewnse of age, sex, merit.] states, race, <br />creed, color, national origin, handicap. religion or Vietnam cra or disabled <br />veteran slams. <br />By: <br />(Sign in ink) <br />(Title) (Date) <br />PREPARED BY (Fiscal) <br />DATE <br />DIVISION APPROVAL <br />DATE <br />DOC DATE <br />CURRENT DOC NO <br />REF DOC NO <br />VENDOR NUMBER <br />VENDOR MESSAGE <br />M <br />TRANS O <br />SUF CODE D FUND <br />APPN PROGRAM <br />INDEX INDEX <br />SUB <br />SUB SUB <br />OBJ OBJ CNTY <br />CITY PROJECT AMOUNT <br />INVOICE GENERAL <br />NUMBER LEDGER <br />APPROVED FOR PAYMENT BY FISCAL <br />DATE <br />WARRANT TOTAL <br />State of Washington • Department of Archaeology 8 Historic Preservation <br />P.O. Box 48343 • Olympia, Washington 98504-8343 • (360) 586-3065 <br />www.dahp.wa.gov <br />