HomeMy WebLinkAboutGrant Related - BOCC (003)FORM STATE OF WASHINGTON
A 19-1A INVOICE VOUCHER
(Rev. 5/91) 7
AGENCY USE ONLY
AGENCY NO.
LOCATION CODE
P.R. ORAUTH.NO.
INSTRUCTIONS TO VENDOR OR CLAIMANT: Su this to im
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, creed, color, nd' rigin, handicap, religio or
� ' a ed y�teraa�ta
BY i
(SIGN IN IN
BOCC Chair
AGENCY NAME
Grant County Health District
1038 W Ivy Ave
Moses Lake, Wa 98837
VENDOR OR CLAIMANT arrant is to be payable to
Grant Integrated Services
Moses Lake HYP 365
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
[05/31/20
Coalition Branding Supplies -Community Coalition
1
$1,126.75
i
Total
$1,126.75
PREPARED BY
Reyna Gonzales
TELEPHONE NUMBER DATE
509 764-2660 107/13/20
AGENCY APPROVAL
i DATE
DOC. DATE
PMT DUE DATE
CURRENT DOC. N0. I
REF DOC.
VENDOR PLUMBER
VENDOR MESSAGE UBI NUMBER
REF j
DOC;
TRANS i
CODE'S
M
0 FUND
MASTER INDEX
SUB
OBJ
SUB
SUB
ORG
INDEX
YJORXCLASS -
Au_oc I
COUNTY
BUDGET
UNIT
CITY/TOWN
Mos
PROJECT
SUB
PROJ I
PROJ
PNAS
AfJOUNT INVOICE NUMBER
APPN PROGRAM
INDEX I q
t
I
�
I
1
I
GRANT COUNTY COMMISSiONMS
ACCOUNTING APPROVAL FOR PAYMENT
DATE I
�I
WARRANT TOTAL WARRANT PLUMBER
I