HomeMy WebLinkAboutRequest to Purchase - GRISFORM STATE OF WASHINGTON
a�'�aia rt'
19-11)
( ° ` y INVOICE VOUCHER
(Rev. 5/91) �• •� ; ,;�'�
Grant Integrated Services
Quincy Partnership For Youth
840 E. Plum Street
Doses Lake, WA 98837
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, dolor, national origin, handicap,. religion, or
Vietnam r i lec vete1�s sta
i
BY
1 INK)
Cindy Carter, WOCC Chair
C
(TITLE) (DATE)
FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S. I RECEIVED BY
DATE I DESCRIPTION QUANTITY UNIT,
05/31/21 1 Cherry Creek Media "You Can" Radio Caml)aizn
PREPARED BY TELEPHONE NUMBER DATE
Reyna Gonzales (509) 764-2660 06/30/21
DOC, DATE I PMT DUE DATE CURRENT DOC, N0, I REF DOC, VENDOR NUMBER
ORG I WORKCLASS I COUNTY
INDEX ALLOC BUDGET
AGENCY APPROVAL
VENDOR MESSAGE
DATE RECEIVED
AMOUNT'FOR AGENCY
USE
141.38
DATE
UBI NUMBER
AMOUNT INVOICE NUMBER
WARRANT TOTAL WARRANT NUMBER