HomeMy WebLinkAboutReimbursable Work Request - GRIS (005)FORM STATE OF WASHINGTON
A 19-1A INVOICE VOUCHER
(Rev. 5/91)
AGENCY USE ONLY
AGENCY NO. LOCATION CODE P.R. OR AUTH. NO.
COW ETED
AGENCY NAME
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INSTRUCTIONS TO VENDOR J417'.-gi,4HHt�#brm 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, national origin, handicap, religion, or
Vietnam er r;,disabled v "terans s s.
�`A V
.a Y
BY
(SIQq IN INK)
BOCC Chair a_���
Grant County Health District
1038 W Ivy Ave
Moses Lake, Wa 98837
VENDOR OR CLAIMANT Warrant is to be payable to
Grant Integrated Services
Quincy Partnership for Youth
8 p
840EPlumSt
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
06130/2020
UTIOY Media Campaign- Facebook Boost for Under the
1
$19.43
06/30/2020
La Pera UTIOY Media Campaign Radio Ads
1
$400.00
06130/2020
Alpha Media UTIOY Media Campaign Radio Ads
1
$1,000.00
06/30/2020
CADCA Mid -Year 2020 Registration
1
$1,425.00
Total
$2,844.43
PREPARED BY
Reyna Gonzales
TELEPHONE NUMBER
509 764-2660
DATE
08/04/20
AGENCY APPROVAL
DATE
DOC. DATE
PMT DUE DATE
I CURRENT DOC. NO.
REF DOC. VENDOR
NUMBER
VENDOR MESSAGE
UBI NUMBER
REF TRANS
DOC CODE
M
0 FUND
MASTER INDEX
SUB
O6d
SUB
SUB OP lPr.T
ORG
INDEX
WORKCLASS
gLLoc
COUNTY
BUDGET
HNIT
CITYROWN
MOS
PROJECT
SUB
PROJ
PROJ
PHAS
AMOUNT
INVOICE NUMBER
AppX
PROGRAM
ILE
ACCOUNTING APPROVAL FOR PAYMENT
DATE
WARRANT TOTAL
WARRANT NUMBER