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an electronic copy of this completd ERF to your <br />portal every month along with any other backup <br />documentation for your monthly financial report <br />(reimbursement request) in eCivis. please submit a <br />financial report each month, even if you are not requesting <br />a relmbursement. <br />Upload <br />Submit this form to Contracton <br />County of Walla Walla, Washington <br />Department of Community Health <br />PO Box 1753 <br />Walla, WA 99352 <br />CIAIMANT <br />I Vendofs Cedtli.ate. I hereby certify unde. penalty of perjury that <br />'theltemsandtotBlslistedherelnar€properchargesformatedals,merchandiseor <br />I seruices furnlshed to the County oi walla Wella and rhat all goodr furnished and/or <br />seruices rendered have been provided without discrimination because of age, sex, <br />maritel stitus, r!ce, ffeed, color, natlonal origin, handicap, religlon, or Vietnam eE or <br />dirabled vetelans rtatus and the claim is jus! due and unpeid obligation againjt thei County of Walla Walla ard that I am authorized to authenticate and ceriltylo :aid <br />lclaim. <br />Expenditure Report Form (ERF) <br />BY: <br />Official <br />ATEMENT FOR SERVTCES - Claim payment for materials, merchandise or services. Show complete <br />INSTRUCTIONS TO VENDOR OR <br />CLAIMANT: <br />YCCTPP <br />22-20.2 <br />Kittitas County Public Health <br />507 N. Nanum, #102 <br />Ellensburg, WA 98926-2886 Program <br />Period: <br />Numberl <br />Jul-23 <br />LINE ITEM DESCRIPTION AMOUNTTHIS <br />lNVOICE <br />Tobacco Prevention Proviso $o.oo <br />Dedicated Cannabis Account So.oo <br />TOTAT PAYMENT REqUESTED WITH THIS ERF;s0.00 <br />PREPARED BY TELEPHONE NUMBER DATE <br />FOR COUNII FINANCE USE ONLY <br />USI NUMBTN <br />FUND Code Dlsattbuilon <br />rccouNltilG APPnov^t to8 PAyMENt DAI€ <br />So,oo <br />WACRANINUMOIB