Walla Walla County Dept of Community Health and KCPHD (YCCTPP) Amend 2

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Expenditure Report Form (ERF) INSTRUCTIONS TO VENDOR OR CLAIMANT. STATEMENT FOR SERVICES - Claim payment 1 Upload an electronic copy of this completd ERF to your eCivis portal every month along with any other backup documentation for your monthly financial report (reimbursement request) in eCivis. Please submit a financial report each month, even if you are not requesting a reimbursement. for materials, merchandise or services. Show complete Vendor's Certificate. I hereby certify under penalty of perjury that the items and totals listed herein are proper charges for materials, merchandise or services furnished to the County of Walla Walla and that all goods furnished and/or services rendered have been provided without discrimination because of age, sex, marital status, race, creed, color, national origin, handicap, religion, or Vietnam era or disabled veterans status and the claim is just, due and unpaid obligation against the County of Walla Walla and that I am authorized to authenticate and certify to said claim. BY: /s/ Authorizing Official (electronic signature) Submit this form t0 Contractor: County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT Kittitas County Public Health 507 N. Nanum, #102 Ellensburg, WA98926-2886 (TITt E) (DATE) Program: Agreement Number: Reporting Period: 2023-24YCCTPP 22-20.2 Jul-23 LINE ITEM DESCRIPTION AMOUNT THIS INVOICE Tobacco Prevention Proviso $0.00 Dedicated Cannabis Account $0.00 TOTAL PAYMENT REQUESTED WITH THIS ERF: $0.00 PREPARED BY TELEPHONE NUMBER DATE FOR COUNTY FINANCE USE ONLY VENDOR NUMBER UBI NUMBER FUND Code Distribution ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANTTOTAL $0.00 WARRANT NUMBER He VV1ed IJ!/lS