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Home My WebLink About*Other - GRISFORM A19-1A (REV. 2020) STATE OF WASHINGTON INVOICE VOUCHER AGENCY USE ONLY AGENCY CONTRACT 1070 K5157 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. 1 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,lmari a status, race, creed, color, nationA i in, handicap, religid or Vietna era or disabled veterans a SrIN BL _ INK indy Carter, hair q,7 DATE AGENCY NAME Health Care Authority 626 8th Avenue SE Olympia, WA 98504-5330 VENDOR OR CLAIMANT (Warrant is to be payable to) Grant Integrated Services 840 E Plum Street Moses Lake, WA 98837 FEDERAL I.D. NO. OR SOCIAL SECURITY NO. **-***9462 RECEIVED BY DATE RECEIVED Professional Services Fidelity Review Services Option 1 (5/3/2021 - 9/30/2021) Service Month and Year DESCRIPTION AMOUNT FOR AGENCY USE May, Aug2021 Actively participated in 2 fidelity reviews including all activities, interviews, report writing, consensus scoring. $10,000 INVOICE NUMBER If Applicable): TOTAL PAYMENT: 10,000.00 PREPARED BY Reyna Gonzales TELEPHONE NUMBER 5097659239 DATE 9/23/2021 AGENCY APPROVAL Dawn Miller, dawn.miIler@hca.wa.gov, 360-522-3544 DATE DOC. DATE PMT DUE DATE CURRENT DOC NUMBER REF DOC NUMBER VENDOR NUMBER VENDOR MESSAGE IBH SVVV0225178-00 REF M DOC TRAN 0 SUF CODE D MASTER INDEX SUB FUND APPN PROGRAM SUB SUB ORG INDEX INDEX OBJ OBJECT INDEX SUB PROJ INVOICE ALLOC MOS PROJECT PROJ PHAS AGREEMENT ID AMOUNT NUMBER K5157 10, 000.00 ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NO. 10,000.00 MTC Form y�rL.m, State of Washington ;f :_ _ , , : K• ,, _ Agency No z . ,:. Agreemantlt) or Co actAlurciber w� Y z` 1070 K5536 A19-1 A Invoice Voucher Health Care Authority 621 8th Avenue SE Vendor's Ce cafe. 1 he y certify under penalty erjury fh t items and totals listed herein are proper charges for materials, merchandise or services fur fished to State Was Olympia, WA 98504 h'ngton, and th t !/ goods n hed an services rendered have been provided without discrimination because age, sex, ital stat ra ,creed, col tiona! origi handicap, religion, or Vietnam era or disabled veterans status. 3..acia.:Y.«f_.....rJ.,... ,c,I.uL,„s..... , ...,..r.... .r..s. �u..,i«(>r_:.,_£:.,..,,•.,..:...M...,.-.r,,.w..<w,...,�T .,. rw ..ra ...!.,_.na»Y.t;...,+.ad.;::i.,.s.,... w�...tas w,�..i wS ��H ,. BY Grant County (sign in ink) 840 E Plum St Moses Lake, WA 98837 vf!�c (title) (date) qr �C✓ TAX IDENTIFICATION NUMBER MONTH/YEAR OF SERVICE (MMiYYYY) RECEIVED BY DATE RECEIVED **-***l 319 - : Au� -21 .t.'« vy. ,:. � �. ,•" is - e ,i .' :, -._''. ,.✓'��-t-� 0,. _ .. 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X14 r A,0.00 126.47 Y ._ rr 22,5 Community Coalition Coordinator Community -Based Process Universal-Direct22.5 Community Coalition Community Based Process Universal -Direct y 3 40.:Y.3. 0.00 S n t 1t 34t 0S,.�3�3 _ ..a:- ,...... .r,�•.' $... .,.... .... ...._ar_, _ t..m.f....- ct..__ t.Y.,:/r_.-_ .+J. ..- Zv� .0rt.t1..-0. .. ow a a exy.. 3. -I...,r.:r. ..._•r,srd.._ ,. _xi.-., `. .-. >. 4. .. K's,:,vx .- ,e .-.. r v.-.„. -� ,_. ., f .Y. ? .._ 1 .. r ,4. o , .Y. ..... .. RrTt..t/.-^.'. .. , T,.. x, ;v5,:.7�,. .: ..nis. .... ...F .. . �. .•,r. rF.€..,.,...,F-,..,.3. ,... S.. . >_ .n•, 5.7 -... ... a..r T. r r.. L.r .�...ir, -.e.k._. . (-3Jh...>..... .l. _. d.� J -.;s.. . N,.5...,..,"t'.._ ..t_ . r' E.._. .3:4 -.-- .... s. ., . ,.. o -f E. >., .: ),.,n. -d'. wt-.arf,tr Yc. a. t ...., .� . r..,. .. ,, y .�.�,'z. p�..�r.. ,9 ittt'�.1....�. .., ✓n,. >" .�. . ..,-.. _t�,t.... ... atm :. : �.q•: r. ;4,...>f 22,1.1 Information Dissemination Universal -Direct 0.00 22.1.2 Information Dissemination Universal -Indirect 0.00 22,1.3 Information Dissemination Selective 0.00 22,1.4 Information Dissemination Indicated 0,00 22.2.1 Education Universal -Direct 0.00 22.2.2 Education Universal -Indirect 0.00 22.2.3 Education Selective 0100 22.2.4 Education Indicated 0.00 22.3.1 Alternatives Universal -Direct 0.00 22.3.2 Alternatives Universal -Indirect 0.00 22.3,3 Alternatives Selective 0.00 22.3.4 Alternatives Indicated 0.00 22.4.1 Problem Identification & Referral Universal -Direct 0.00 22.4.2 Problem Identification & Referral Universal -Indirect 0.00 22.4.3 Problem Identification & Referral Selective 0.00 22.4.4 Problem Identification & Referral Indicated 0.00240.58 22.5.1 Coordinator Technology Supplies -Program Start -Up Cost Community -Based Process Universal -Direct 0.00 240.58 22.5.2 Community -Based Process Universal -Indirect 0.00 22.5.3 Community -Based Process Selective 0 .00 22.5.4 Community -Based Process Indicated 22,6,1 Environmental Universal -Direct 0.00 0.00 22.6.2 Environmental Universal -Indirect 0.00 22.6.3 Environmental Selective 0.00 22.6.4 Environmental Indicated 0.00 22.7.1 Other Universal -Direct 0.00 22,7.2 Other Universal -Indirect 0.00 22.7.3 Other Selective 0.00 22.7.4 Other Indicated 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -, reY 'Jv K = 1 i< 4 "l.Lr .. L '•.f .C' �t Z . C- Y� /r. .rY ,. 4:S '..0 4Kj r . -- �. .: L........l 0.00 Y: .r _ -, t.t �t. , 4.n . r., i., k.,F rz rw. .. f ro- .-, ..._.. .Y 8.- f 4'. .+ i_ __> . .„t . .e. . , t .r . ., .�_.1 .^.... +_.. . ... .= .:r ,.... ., . .rr.-..-,. �`.-,x... . .}.. F i. ,1. .. .K.. ,. , _ r_ s..-__. _ t.,. -. ... .,,r. 1 z. .- ...,.✓...._,. fir.- . , s,_. . , r ,l v,_ t .-..5.. . v., ..-,.. .,. ._......,. ae....l.. _: ,..( u . -: •,.f J...i:,J. ..- �. - rt_Z�ao : o ... PREPARED BY/ DATE TELEPHONE Reyna Gonzales 09/22/2021 509 764-2660 A19:Effecttve 71.1(2021 throgh 6130/2023 kEVISED 712021 u CURR DOC NO DOC DATE VENDOR NO. AGENCY APPROVAL. SWV0002426-00 Sarah Marian!, 360-725-9401, Sarah .Marianl@hca.wa.gov ACCOUNTING APPROVAL FOR PAYMENT! DATE [ per, a r� r r 1 fl u Uzi Juy sr��-^-s_p^F.'�ar�`�'•�ar3s.`-rcdc x -.F< .—ate, •'-i_�.`�:...ar s3:6�-roc.:cj Form �' State of Washington�, r Agreemani,lil ar Gantract[Vumbe- A19-1 A f� �;�. ��' Invoice Voucher 1070 K5536 Health Care Authority 621 8th Avenue SE Olympia, WA 98504 Vendor's Certfficate. I hereby certify under penalty f perjury that the items and totals listed herein are pro r charges for materials, m services fur ' to the State of Washi on, and tha all goods furnished and/or services rendered have an provided without discrimi because e, se ,\arita status, rac reed, col , tional origin, handicap, religion, or Vietnam era r disabled veterans status. Grant County BY (sign in ink) 840 E Plum St Moses Lake, WA 98837 Cindy Carter, Chair ct., (title) (date) TAX IDENTIFICATION NUMBER * *1319 MONTHIYEAR OF SERVICE (MMIYYYY) RECEIVED BY Aug -21 DATE RECEIVED .:... 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J..:, .."r,., ,: s'-�. .;_ 3 ' 22.1.1 Information Dissemination Universal -Direct 22.1.2 Information Dissemination Universal -Indirect 22.1.3 Information Dissemination Selective 22.1.4 Information Dissemination Indicated 22.2.1 Education Universal -Direct 22.2.2 Education Universal -Indirect 22.2.3 Education Selective 22.2.4 Education Indicated 22.3.1 Alternatives Universal -Direct 22.3.2 Alternatives Universal -Indirect 22.3.3 Alternatives Selective 22.3,4 Alternatives Indicated 22.4.1 Problem Identification & Referral UniversahDirect 22.4.2 Problem Identification & Referral Universal -Indirect 22.4.3 Problem Identification & Referral Selective 22.4.4 Problem Identification & Referral Indicated 22.5.1 Coordinator Technology Supplies -Program Start -Up Cost Community -Based Process Universal -Direct 0.00 240.58 .22.5.2 Community -Based Process Universal -Indirect 22.5.3 Community -Based Process Selective 22.5.4 Community -Based Process Indicated 22.6.1 Environmental Universal -Direct 22.6.2 Environmental Universal -Indirect 22.6.3 Environmental Selective 22.6.4 Environmental Indicated 22.7.1 Other Universal -Direct 22.7.2 Other Universal-Indire 22.7.3 Other Selective 22.7.4 Other Indicated > ,{>, 1. , .. . .... _. ,. ". , ... '. ..:. ." '.. .-T .... ._ .. :...... .. ..... u. r 3 - 00 PREPARED BY/ DATE TELEPHONE .O7 rfl Reyna Gonzales 09/22/2021 509 764-2660 A19 Effective 7/1/2021 through 6/30/2023 REVISED 712021 CURR DOC NO DOC DATEVENDOR NO. AGENCY APPROVAL. ACCOUNTING APPROVAL FOR PAYMENT/ DATE SVVV0002426-00 Sarah Marian!, 360-725-9401, Sarah.Mariani@hc r /0-�2--Z14-