HomeMy WebLinkAboutInvoices - Central ServicesFORM STATE OF WASHINGTON
A 19-1A INVOICE VOUCHER
(Rev. 5/91)
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AGENCY
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 and/or
services rendered have been provided without discrimination because of age,
sex, marital status, race, creed, color, tional origin, handicap, religion, or
Viet Jeralablekran tatus.
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Washington State Department of Agriculture
Fairs Program
PO Box 42560
Olympia, WA 98504-2560
VENDOR OR CLAIMANT arrant is to be pa able to
Grant County (Grant County Fair)
Attn: County Treasurer
PO Box 37
Ephrata, WA 98823
(TITLE) (DATE)
FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S.
RECEIVED BY
DATE RECEIVED
DATE
DESCRIPTION
QUANTITY
UNIT
PRICE
AMOUNT
FOR AGENCY
USE
INTERAGENCY AGREEMENT NO. K2926
1
45,000
45,000.00
Special Assistance Grant — Grant County Fairgrounds,
Total Due
$45,000.00
PREPARED BY
TELEPHONE NUMBER
DATE
AGENCY APPROVAL
DATE
DOC. DATE
PMT DUE DATE
I CURRENT DOC, NO.
REF DOC. I VENDOR
2426-40
NUMBER
VENDOR MESSAGE
UBI NUMBER
REF TRANS
DOC CODE
M MASTERINDEX
O FUND APPN PROGRAM
INnFX
INDEX
SUB
OBJ
SUB
SUB
ORG
INDEX
WORKCLASS
ALLOC
COUNTY
BUDGET
UNIT
CITYITOWN
Mos
PROJECT
SUB
PROJ
PROD
PHAS
AMOUNT
INVOICE NUMBER
057 A00
64460
ACCOUNTING APPROVAL FOR PAYMENT
DATE
WARRANT TOTAL
WARRANT NUMBER