HomeMy WebLinkAboutReimbursable Work Request - Renew (004)Form;
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Grant County Health District
1038 W Ivy Ave
Moses Lake, WA 98837
INSTRUCTIONS To VENDOR OR CLAIMANT:
Submit this form to claim payment for maierlals, merchan.dl$e or sorviaes. Show complete
detall for each Item.
Vendor's Certificate; i hereby aertify under penalty of perjury that -the Items and katals
listed hare are proper charges f
p P g 4r ma�artats merchandise or s
� ervlces furnished to the
state Of was
VENDOR OR CLAIMAN (Warrant is to he payable to)
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if C �' C1 `i U l (,Pj
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and that all goads furnis d an.dlar ery
�� Ices rendered nava been
provlded w � cit disci i atlon bac o of ttg ex, marital Jltatus, race, creed, color,
national o cel handicap, ligion, o V to a a disabled veterans slates.
1
By
Cindy Carter, alair
--Month: A ."Lcr
Amount
ul �f
Salaries
.-Benefits
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Goods & SarviceS
f
Indirect Costs
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Total
Propared by Date t A6snoy Approval Data
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I nteragen cy% Agre em em G ra lit I nteg .. t}. d S vir ,us
Page 9