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Exhibit H <br />Recreational Boating Sofety Federol Financial Assistonce Grant <br />lnvoice Voucher <br />!1 <br />FORM 419-1A <br />(Rev s/91)@ State of Washington <br />lnvoice Voucher <br />Award Amount Contract Number Contract Term <br />s 92,170 nla 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 pavable to) <br />Kittitas County Sheriff's Office <br />307 W Umptanum Road <br />Ellensburg, WA 98926 <br />INSTRUCfIONS TO VENDOR OR CLAIMANT: <br />Submitthisform to cloim paymentt'or materiolt merchondise or services. <br />Use the worksheets in tobs 2-3 to auto complete this Jorm. <br />Vendor's Certificatei I hereby certify under penalty of perjury that the items and <br />totals listed herein are proper charges for materials, merchandise or servicesfurnishedto the State of Washington, and that all goods furnished and/or servicesrendered have been provided without discrimination because of age, sex, marital <br />status, race, creed, .olor, national origin, handicap, religion, or Vietnam era or <br />disabled veterahs status. <br />Signoture Dote <br />Print Nome Title <br />Contact for billing questions Title <br />Corey Tolar Fiscal Analyst <br />Email Address Phone <br />corev.tolar(a parks.wa.eov 360-902-8595 <br />Quarter Description Units Amount Agencv Onlv <br />0 <br />Rec. Boating Safety Officer Patrol Hours see ottoched $ <br />The totol hours for oll RBS trotned ot't'icers for on-the-woter pqtrol; ollowable reimbursement includes solories, benefits and woges. <br />Adventures in Boating Safety Education see ottoched s <br />Adventures in Booting closses instructor time, ddvertising, supplies, rent, etc. dnd booting sofety moteriols. <br />Equipment see ottqched s <br />Purchase, mointenonce ond operotion of pqtrol boots ond patrol boot <br />operotions or homeland security missions. <br />equipment to perlorm the RBS mission - DOES NOT include equipment for recovery <br />Rec, Boating Safety Officer Training see ottached $ <br />Courses offered to officers to complete the RBS misslon which ore sponsored by Stote porks <br />Other Expenditures see attoched s <br />Use the "Reimbursement Worksheet" tob to expldin other ollowable <br />totol this billing s <br />Do not write below this shaded line <br />(unless enterlng Stdte-Wlde Vendot Numheil <br />Prepared bv Telephone number Date Asencv Aoproval Date <br />Doc Date Pmt due date Current Doc. No.Ref or Number Vendor Message UBI Number <br />Ref Doc <br />Trans <br />Code MOD Fund Master lndex <br />Sub <br />obi <br />s-5 <br />obiect MOS Proiect Sub Proi Amount lnvoice Number <br />APPROVAL FOR PAYMENT DATE A19-1A