HomeMy WebLinkAboutReimbursable Work Request - Renew (002)•
Forte State of Washington
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INVOICE VOUCHER
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AGENCY NAME
Grath County Health District
1038 W V v
Mases Lake} WA 98837
STRUr,TIONS TO VENDOR OR CLAIMANT:
Submit this form to cialrn ;)ay€nent for materials, Merchandise or saNices. Shaw complete �
detail for each item.
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VENDOR OR CLAIMANT (warrant Is to be payable to)
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Vendor's Certificate: I hereby aQrtffy under pena�6ty of perjury that the Items and totals
fisted herel are e proper c>Sarges for matartats, merchandise
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or services furnished to the
Slate of Washln ton, and that all gti ds fur ed andior sarvlces rendered have been
proyided w+itho i
cointion be a sa of u Sax, status, racs, cread, {
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color,
nationaltarl dlcap, I4�, o iatnam s a f disabled vetvans status. � I
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Cindy Carter, hair- e_> - D-,��c ,
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(Title) (data} 1
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Month:Am
ount
Salaries
Benefits
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Goods & SarviceS
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Indirect Costs
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