HomeMy WebLinkAbout*Other - GRISFORM STATE OF WASHINGTON
19 -IA INVOICE VOUCHER
(Rev. 5/91);�T
lRti9 '
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
AGENCY USE ONLY
AGENCY N0, LOCATION CODE P.R. OR RUTH. 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, mari s, race, creep, co or, ational origin, handicap, religion, or
Vietna era or disa ted vetera status. f�
BY I A I
(SIG N K}
Cindy Cdrier, .fibCC Chair
(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.: :. � :.
DES
. CRIPTION - ::: '` , .. 'FOR
Q ANTITY
�> U N
U IT . ; AGENCY
.`AMOUNT
Middle School SPORT curriculum and training for 4 USE.-
r •1..
05/18/21 1 "You Can" promo items
4 2792.00
1891.66
TOTAL
PREPARED BY TELEPHONE NUMBER DATE
Reyna Gonzales (509) 764-2660 05/26/21
DOC. DATE PMT DUE DATE CURRENT DOC. N0. REF DOC. VENDOR NUMBER
REF M DOC TRANS FUND MASTER INDEX SUB ` SUB ORG WORKCLASS COUNTY CITY/TOWN
CODE APPN PROGRAM OBJ SUB INDEX ALLOC BUDGET
INDEX INDEX UNIT MOS
4,683.66
AGENCY APPROVAL DATE
VENDOR MESSAGE UBI NUMBER
PROJECT SUB ; PROJ AMOUNT INVOICE NUMBER
PROJ. PHAS .
ACCOUNTING
APPROVAL
FOR PAYMENT
DATE
WARRANT TOTAL
WARRANT NUMBER