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Ag6ne-Y-Uso,00Y
Form State ofWashington
Al 0-1 AAgone'y Lod Iflon.Code P.R, or
INVOICE VOUCHER No, ;,a I I
.. .. ... Auth.-No..
AGENICY NAME
INSTRUOTIONS TO VENDOR OR CLAIMANT:
Submit this form to c1nim payment for materials, merchandise or services. Show aomplete
Grant County Health District
1038 W Ivy Ave
Moses Lake, WA 98837
detail for each Item,
Vendorls Certificate'. I hereby cmrfffy under penaIty of perjury that -the Items and totals
listed hare.1n are proper charges for materlats, merchandise ¢rservicesfurnished to t 0
h
VENDOR OR C:LAWAN'T (warrant is to be payable to)
ce '(-cA A
State df Washington, and 111,11 all g6ods furnished andlor sarVIce$ rendered have been
provided hout disorlml 0 bei "86 of age, sex, marital status, raca, creed, color,
iniation, br In, andt ap,11011 I n,,ory team era or disabled veterans status.
(Sig
By OPP-
Cindy Car r, Chair
(Title)(Date)
Month: W
Amo unt
Salaries
Benefits
4\A
Goods & SerViCeS
Indirect Costs
Total
Prepared by Date Agency Approval Date
Ila 6
Interagency Agreement - Graaf I ntegra.t e*dSe. i,v'
ices 77M 619
Page 9