HomeMy WebLinkAboutReimbursable Work Request - Renew (004)0
Agency Use Only
Form S ,tate of Washington
Al 9-1 AAgency Location Code P.R. or
Rev. - 5 1 1 1 91) ................. INVOICE VOUC " HER No. Auth. No.
I'M— kow6wo-1 I., W 1 11
AGENCYNAME
..G . ...... .. . rant County Health District
1038 W ivy Ave
Moses Lake, WA 98837
VENDOR OR CLAIMANT (Warrant is to "be payable to)
Grc�ra Thi fru}eel ��„�ey
�U.�,..ey ���-S�S�r�Q �w ��r0 kh
11IU�iS �5,�-��2 � V� r �`63�
INSTRUCTIONS TO VENDOR OR CLAIMANT4
Submit this form to claim payment for materials, morthandise or services. Show complete
detail for each Item.
Vendor's Certificate: I hereby certify under penalty of pejury that the items and totals
listed hereinare proper charges for materials, merchandise or services furnished to the
M C
ftte o a, on, and that all, go9qs fu N-he.d�andlo't services 'rendered have been
p ovi s x :mantel status, race, . creed, ed, color,
r -d wi out 0 nation boo U* of agq s man
natio al orifi handic ligion, or
.11nam or or ab.ted veterans status,
($19 ature)
A
BY , �,Z,UV _ L I....
Cindy Carter, L:hair
(TIU6)
(D �_q.,-ZI) 1
Month,
Amount zS
Salaries
LA S'
.Benefits
Goods & Services
Indirect Costs
Total
Prepared by
Date
-------------- ---
Agency Approval
Date
211 WIN M i 111 1111111 ... ONION 1 1 01 1
-30/2.0
interagency Agreement — G 20 I
9;
14AR
[GRANT COUNTY COMMISSIONERS