HomeMy WebLinkAboutReimbursable Work Request - Health DistrictFORM STATE OF WASHINGTON
A 19-1A ° ` r, INVOICE VOUCHER
(Rev. 5/91) j1 f 1),
AGENCY NAME
Grant County Health District
1038 W Ivy Ave
Moses Lake, WA 98837
VENDOR OR CLAIMANT (Warrant is to be payable to)
Grant Integrated Services
Moses Lake Community Coalition
840 E. Plum Street
Moses Lake, WA 98837
+ (2-7,w C_ Aei-� 0,�,J ?ao S iLAV--,
AGENCY USE ONLY
AGENCY NO. LOCATION CODE P.R. OR AUTH. N0.
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, cr ed, colof, national origin, handicap, religion, or
Vjei6 >a elta,Ar disabled vete s statue
\► ISIGN IN INK)
Cindy Carter, Chair
FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S. I RECEIVED BY
(TITLE)
(DATE)
DATE RECEIVED
DATE
DESCRIPTION
QUANTITY
UNIT
AMOUNT
FOR USE AGENCY
02/01/21
Sand Timers; Setup Fees
200
1.16
$333.87
02/01/21
Cups; Setup Fees
250
.57
$224.94
02/01/21
Magnets
250
.45
$142.55
02/01/21 I Bads
-]Tota 1
PREPARED BY
Reyna Gonzales
DOC. DATE I PMT DUE DATE
TELEPHONE NUMBER DATE
509 764-2660 03/19/21
CURRENT DOC. N0. I REF DOC. FVENDOR NUMBER
1400 1 .54 1 $932.34
AGENCY APPROVAL
VENDOR MESSAGE
REF M
OC CODE TRANS FUND MASTER INDEX SUB SUB ORG WORKCLASS COUNTY CITY/TOWN SUB PROD
APPN PROGRAM OBJ SUB INDEX ALLOC MOS PROJ PHAS
St IFINDEX INDEX B UNGT T PROJECT
ACCOUNTING APPROVAL FOR PAYMENT DATE
$1,633.70
DATE
UBI NUMBER
AMOUNT INVOICE NUMBER
WARRANT TOTAL I WARRANT NUMBER