Laserfiche WebLink
Exhibit H <br />Recreational Boating Safety Federal Financial Assistance Grant FORM A19-1AState of Washington <br />..,. <br />Invoice Voucher (Rev S/91) Invoice Voucher <br />Award Amount I Contract Number Contract Term <br />$ 92,170 n/a Sept 1, 2022 -Sept 30, 2024 <br />CFDA 97.012 <br />AGENCY NAME <br />Washington State Parks and Recreation Commission <br />Boating Program <br />PO Box 42650 <br />Olympia, WA 98504 <br />VENDOR OR CLAIMANT (Warrant is to be oavable to) <br />Kittitas County Sheriff's Office <br />307 W Umptanum Road <br />Ellensburg, WA 98926 <br />Contact for billing questions <br />Title <br />Corey Tolar <br />Fiscal Analyst <br />Email Address <br />Phone <br />core .tolar arks.wa. ov <br />360-902-8595 <br />INSTRUCTIONS TO VENDOR OR CLAIMANT.. <br />Submit this form to claim payment for materials, merchandise or services. <br />Use the worksheets in tabs 2-3 to auto complete this form. <br />Vendor's Certificate: I hereby certify under penalty of perjury that the items and <br />totals listed herein are proper charges for materials, merchandise or services <br />furnished to the State of Washington, and that all goods fumished and/or services <br />rendered have been provided without discrimination because of age, sex, marital <br />status, race, creed, color, national origin, handicap, religion, or Vietnam era or <br />disabled veterans status. <br />Signature <br />Print Name <br />Date <br />Title <br />Quarter <br />Description Units Amount Agency Only <br />Rec. Boating Safety Officer Patrol Hours see attached $ <br />The total hours for all RBS trained officers far on -the -water patrol; allowable reimbursement includes salaries, benefits and wages. <br />Adventures in Boating Safety Education <br />I see attached <br />$ - <br />Adventures in Boating classes instructor time, advertising, supplies, rent etc. and boating safety materials. <br />Equipment <br />I see attached <br />$ <br />a <br />Purchase, maintenance and operation of patrol boats and patrol boat equipment to perform the RBS mission - DOES NOT include equipment for recovery <br />operations or homeland security missions. <br />Rec. Boating Safety Officer Training <br />see attached <br />$ <br />Courses offered to officers to complete the RBS mission which are sponsored by State Parks <br />Other Expenditures <br />see attached <br />$ <br />Use the "Reimbursement Worksheet" tab to explain other allowable expenditure(s). <br />total this billing <br />$ - <br />Do not write below this shaded line <br />(unless entering State -Wide Vendor Number) <br />Prepared by <br />Telephone number <br />Date Agency Approval <br />Date <br />Doc Date <br />Pmt due date <br />Current Doc. No. <br />Ref. <br />Vendor Number <br />Vendor Message <br />UBI Number <br />Ref Doc <br />Trans <br />Code <br />MOD <br />Fund <br />Master Index <br />Sub <br />Ob' <br />S -S <br />object <br />MOS <br />Project <br />Sub Proj <br />Amount <br />Invoice Number <br />APPROVAL FOR PAYMENT <br />DATE <br />A19 -1A <br />1/1 <br />