HomeMy WebLinkAboutGrant Related - Central ServicesFORM STATE OF WASHINGTON
A19 -1A
INVOICE VOUCHER
(Rev. 5/91)
AGENCY USE ONLY
AGENCY NO., LOCATION CODE P.R. OR RUTH. NO.
I I I
AGENCY NAME
INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claim
payment for materials, merchandise or services. Show complete detail for
each item.
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 State of Washington, 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.
BY
N IN INK)
CkA a -
(TITLE) (DATE)
C. *&J C5
Washington State Department of Agriculture
Fairs Program
PO Box 42560
Olympia, WA 98504-2560
VENDOR OR CLAIMANT (Warrant is t® be payable to),
Grant County (Grant County Fair)
Attn: County Treasurer
PO Box 37
Ephrata, WA 98823
FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S.
RECEIVED BY
DATE RECEIVED
DATE:
-DESCRIPTION
QUANTITY
UNIT
PRICE
:AMOUNT
FOR
-�'AGENCY
USE
INTERAGENCY AGREEMENT NO. K3675
1
250,000.
250,000.00
Capital Improvement Grant — Musco Lighting Project
Total Due,
$250,000.00
PREPARED BY
TELEPHONE NUMBER
DATE
AGENCY APPROVAL
DATE
DOC, DATE
PMT DUE DATE
CURRENT DOC. NO.
REF DOC.
VENDOR NUMBER
2426-40
VENDOR MESSAGE
UBI NUMBER
REF
DOC
TRANS
CODE
M
0 FUND
n
MASTER INDEX
SUB
OBJ
SUB
SUB
ORG
INDEX
WORKCLASS
ALLOC
COUNTY
BUDGET
UNIT
CITY/TOWN
MOS
PROJECT
SUB
I PROJ
PHAS
AMOUNT
INVOICE NUMBER
APPN
INDEX
PROGRAM
INDEX
,057
COO
64450
It 'i
4
ACCOUNTING APPROVAL FOR PAYMENT
DATE
WIRRANT TOTAL
51
WARRANT NUMBER
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