HomeMy WebLinkAbout*Other - GRISFORM STATE OF WASHINGTON
A 19-1A INVOICE VOUCHER
( Rev. 5/91)
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AGENCY NAME
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
840 E. Plum Street
Moses Lake, WA 98837
FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S.
DATE DESCRIPTION
Middle School SPORT curriculum and training for 4
05/10/21 facilitators
05/18/21 "You Can" promo items
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AGENCY USE ONLY
AGENCY NO. LOCATION CODE P.R. OR AUTH. NO.
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, m status, race, ceed, colo national origin, handicap, religion, or
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BY � k I I I A/1)
(SIGN INK)
Cindy Carte, BOCC Chaii
(TITLE) (DATE)
RECEIVED BY DATE RECEIVED
QUANTITY UNIT
4
AMOUNT FOR AGENCY
USE
2792.00
1891.66
4,683.66
DATE
UBI NUMBER
AMOUNT INVOICE NUMBER
ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARR
TOTAL
PREPARED BY
Reyna Gonzales
TELEPHONE NUMBER
(509) 764-2660
DATE
05/26/21
AGENCY APPROVAL
DOC. DATE
PMT DUE DATE
CURRENT DOC. NO.
REF DOC.
VENDOR NUMBER
VENDOR MESSAGE
REFM
DOC
.1 IF
TRANS
CODE
0 FUND
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MASTER INDEX
SUB
OBJ
SUB
SUB
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ORG
INDEX
WORKCLASS
ALLOC
COUNTY
BUDGET
, ,,,,T
CITY/TOWN
MOS
PROJECT
SUB
PROJ
PROJ
PHAS
APPN
INDEX
PROGRAM
INnFY
AMOUNT FOR AGENCY
USE
2792.00
1891.66
4,683.66
DATE
UBI NUMBER
AMOUNT INVOICE NUMBER
ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARR