HomeMy WebLinkAboutInvoices - BOCC (004)Form STA State of Washington
A19 -11A INVOICE VOUCHER
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ADMINISTRATIVE OFFICE OF THE COURTS
PO BOX 41172
OLYMPIA WA 98504-1172
FEDERAL LD, NO. OR SOCIAL SECURITY NO. or Reporting Personal Services Contract Payments to I.R.S,)
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AGENCY USE ONLY
TELEPHONE NUMBER
0550
1
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 and/or services rendered have been provided without
discriminations because of age, sex, marital status, race creed, color,
national origin, religion, or Vietnam era or disabled veterans status.
BY
PREPARED BY
TELEPHONE NUMBER
DATE
IVENDOR
DOC DATE
DATE
PMT DUE DATE
CURRENT DOC NO,
REF, DOC, NO.
NUMBER
REF
M
pip-, "lly
SUB WORK CLASS
COUNTY CITYj
000 TRANS
I
0 FUND
PROGRAM SUB
SUB ORG ALLOC
BUDGET M
SUF CODE
I DI INDEX
11
INDEX 0131
OBJECT INDEX
UNIT
UNTING APPROVAL FOR PAYMENT JDATE
to I Ad -Z I
(UM
:X
IDATE RECEIVED
AGENCY APPROVAL
USE VENDOR MESSAGE r E TAX I USI NUMBER
PROJECT I SUB PROJ AMOUNT
PROJIPHAS
DATE
INVOICE
NUMBER