HomeMy WebLinkAboutGrant Related - GRISFORM STATE OF WASHINGTON
A 19-1A INVOICE VOUCHER
(Rev. 5/91)KI
COMPLETED
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,
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 and/or
services rendered have been provided without discrimination because of age,
sex, marital status,race, cre , color, tional origin, handicap, religion, or
Vietnam era or di A81ed vetera s status.
BY
BOCC Chair AGN lltll U
ou
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
06/30/20
PAX Tool Kit Supplies (Branded T -Shirts)
1
$2,113.80
06/30/20
PAX Tool Kit Supplies (Branded Lanyards)
1
$415.70
06/30/20
Community Coalition (Coalition Supplies)
1
$1,019.50
Total
$3,549.00
PREPARED BY
Reyna Gonzales
TELEPHONE NUMBER
509 764-2660
DATE
08/04/20
AGENCY APPROVAL
DATE
DOC. DATE
PMT DUE DATE
I CURRENT DOC. N0.
I REF DOC.
VENDOR NUMBER VENDOR MESSAGE UBI NUMBER
REF TRANS M MASTER INDEX SUB SUB ORG WORKCLASS COUNTY CITY/rOWN PROJECT SUB PROJ AMOUNT INVOICE NUMBER
DOC CODE 0 FUND AppN PROGRAM OBJ SUB INDEX ALLOC BUDGET MOS PROJ I PHAS
ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NUMBER