HomeMy WebLinkAboutReimbursable Work Request - Renew (003)I
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Form
Al M A state ofWas-h'Ington AgOric'y* Loq`allon.Codo
(Rev, SIDI) INVOICE VOUCHER No,, I P.R, or
Auth.-Not.
0
AME
Grant fk'_"*1ountY Health District
1038 W Ivy Ave
Moses Lake,'WA 98837
I VENDOR OR CLAIMANT (warrant Is to be payable to) - 7
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M onth.,
Salaries
Benefits
Goods & Services
Indirect Costs
Amount
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INSTRUCTIONS TO VENDOR OR CLAIMANT:
Submit this form to -claim payment for materials, rnercharidi!a Dr services. Show complete
detail for each Item.
Vendor's Cartificate; I hereby certify under penalty of perjury that -the Items and totals
listed herolli are, proper charges for matertal , merchandise or servIces furnished to the
-it all gdods fern bed andlar serAces rund0red have been
State Of Washington, and tip. -if I
provIded with i discrimin'atlon be so f a sex, marital status, rata, creed, color,
national q Ca rallgion, r latna
Y1Jq 0a M r or divibled veterans slatus<
se
or
Cindy Carter, 16hai`r'
(TH10) (Date)
Total
Prepared by DateP _"W
I I Agenc4y Approval F Date