HomeMy WebLinkAbout*Other - GRIS (002)FORM STATE OF WASHINGTON
A19 -1A INVOICE VOUCHER
(Rev. 5/91)
AGENCY USE ONLY
AGENCY NO. LOCATION CODE P.R. OR RUTH. NO.
AGENCY NAME
INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claim
Grant County Health District
1038 W Ivy Ave
payment for materials, merchandise or services. Show complete detail for
each item.
Moses Lake, WA 98837
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
VENDOR OR CLAIMANT (Warrant is to be payable to)
furnished to the State of Washington, and that all goods furnished and/or
Grant Integrated Services
services rendered have been provided witho t discrimination because of age,
Moses Lake Community Coalition
I
sex, marital s tus, race creed, r, natio I I origin, handicap, religion, or
"
Vietnam e o isa I d terans to us.
840 E. Plum Street
Moses Lake, WA 98837
BY
(SIG IN INK1�--
Cindy Carter, BOCC Chair
(TITLE) (DATE)
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
AMOUNT
FOR AGENCY
USE
Youth Empowerment & You Can -Extreme Beauty/T-
05/27/21
shirts
200
2853.27
y✓
NA L- 14
TOTAL
2853.27
PREPARED BY
TELEPHONE NUMBER
DATE
AGENCY APPROVAL
DATE
Reyna Gonzales
(509) 764-2660
05/28/21
1
DOC, DATE
PMT DUE DATE
CURRENT DOC. NO.
REF DOC. VENDOR
NUMBER
VENDOR MESSAGE
UBI NUMBER
REF
DOC
TRANS
CODE_
0 FUND
MASTER INDEX
SUB
OB-
SUB
SUB
ORG
INDEX
WORKCLASS
ALLOC
COUNTY
BUDGET
CITY/TOWN
Mos
PROJECT
SUB
PROJ
PROJ
PHAS
AMOUNT
INVOICE NUMBER
APPN
_
PROGRAM
-.ql IF
INDEX
INDEX
0R.1FGT
UNIT
V4
ACCOUNTING APPROVAL FOR PAYMENT
DATE
WARRANT TOTAL
%
WARRANT NUMBER