HomeMy WebLinkAboutReimbursable Work Request - Renew (003)Agency Use Qnly
ate of Washington,
Al 9-1 A `` �} 11 C)lAgency Location Cade P.R. or
rtev. /91wm Auth. No.
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AGENCY NAM
Grant County Health District
1038 W Ivy Ave
INSTRUCTIONS TO VENDOR OR CLAIMANT:
Submit this form to claim payment for materials, merchandise or services. Shaw complete
Moses Labe, WA 9883
detail for each iters.
Yondoes Certificate. l he.relay certify under penalty of perjury that the items and totals
proper charges, , merchandise �'?�` ser'�f1GeS f4JCl11SietI to the
,Mate of Was ington, and that goads f ,`rushed and/or services rendered have been
VENDOR OR CLAIMANT (Warrant is to be payable to)
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provided unit seri inativ ecause a` e, sex, marital status, race, creed, color,
national or! han ka reli r n r ietn er or disabled � � d eterans status.
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By
CindyCarter,khair
(rifle) (Date)
Month:
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Amount � �[
Salaries
B,enefits
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Geode& -Services
Indirect Casts
Total
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Date
Agency Approval
late
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