HomeMy WebLinkAboutReimbursable Work Request - Health District (002)FORM STATE OF WASHINGTON
A 19-1A INVOICE VOUCHER
(Rev. 5/91) 0
AGENCY USE ONLY
AGENCY NO. LOCATION CODE P.R. OR AUTH. NO.
AGENCY NAME
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 andior
services rendered have been provided without discrimination because of age,
sex, marital status, race, creed, color, national origin, handicap, religion, or
Vietnam era or 'spd veterqns status.
i
V
BY
(SIG I
Cindy Carter, BOC Chair -9
Grant County Health District
1038 W Ivy Ave
Moses Lake, Wa 98837
VENDOR OR CLAIMANT arrant is to be payable to
Grant Integrated Services
Partnership fYouth
Quincy Porout
840 E Plum St
Moses Lake, Wa 98837
(TITLE) (DATE)
FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S.
91.6001319
RECEIVED BY
DATE RECEIVED
DATE
DESCRIPTION
QUANTITY
UNIT
AMOUNT
FOR AGENCY
USE
04/30/2020
Trauma -Informed School Literature- Quincy
1
74.94
04/30/2020
Conference Phone System- Quincy
1
324.25
04/30/2020
Interactive Presentation Platform- Quincy
1
299.88
Total
$699.07
PREPARED BY
Reyna Gonzales
TELEPHONE NUMBER
509 764-2660
DATE
06/03/20
AGENCY APPROVAL
DATE
DOC. DATE
PMT DUE DATE
CURRENT DOC, NO.
REF DOC. VENDOR
NUMBER
VENDOR MESSAGE
UBI NUMBER
REF TRANS
DOC CODE
M
O FUND
MASTER INDEX
SUB
OBJ
SUB
SUB
ORG
INDEX
WORKCLASS
AL�oc
COUNTY
BUDGET
UNIT
CITYITOWN
MOS
PROJECT
SUB
PROJ
PROJ
PHAS
AMOUNT
INVOICE NUMBER
APPN
INDEXSUEX
PROGRAM
ACCOUNTING APPROVAL FOR PAYMENT
DATE
WARRANT TOTAL
WARRANT NUMBER