HomeMy WebLinkAboutReimbursable Work Request - GRISForm
A19-IA v
-
Health Care Authority
PO Box 42691
Olympia WA 98504
Grant County
W E Plum Street
Moses Lake, WA 98837
Sete of Washington=_
Invoice Voucher
•: ,tea ,^� a
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0701763-94250
Vendors Cerlificate. I hereby certify under penalty of perjury that the items and totals listed hereN are proper charges for matenals, mercharMse or services furnished
to theState of Washington, and that all goods famished and/or services rendered have been provided without discrimination because of age, u . marital staa/s, race,
reed, color, national origin, handicap. religion, or Vietnamera or disabled veterans status.
-TTff&l �-
(sign in ink)
Tom Taylor BOCC Chas 3A Iq
(title) (date)
TAX IDENTIFICATION NUMBER
Admin
21 Community-Based Coordination-Px
22.5 Community Coalition Coordinator
MONTH OF SERVICE
Jan-19
Community-Based Process Universal-Indirect
Community-Based Process Universal-Direct
RECEIVED BY DATE RECEIVED
510.83 187.56 4.08
152.23 1
854.71
22.5 Community Coalition
Community-Based Process
Universal-Direct
22.5.1 Community Coalition Coordinator - ML
Community-Based Process
Universal-Direct
7,042.83 _
7,042.83
22.5.1 Community Coalition -ML
Community-Based Process
Universal-Direct
118.75
118.75
22.7.1 CADCA Boot Camp- Meals -ML
Other
Universal-Direct
297.00
297.00
22.71 Resiliency Conference- Speaker- ML
Other
Universal-Direct
531.05 -
531.05
22 7.1 PAX GBG Facilitator Training- ML
Other
Universal-Direct
- -- 51.00
51.00
22.5.1 Community Coalition Coordinator- Quincy
Community-Based Process
Universal-Direct
1 1,940.03
1,45223
3,392.26
22.5,1 Community Coalition -Quincy
Community-Based Process
Universal-Direct
107.50
107.50
22.7.1 CADCA Boot Camp- Meals -Quincy
Other
Universal-Direct
297.00
297.00
2271 New Coordinator Training - Meals and Hotel- Quincy
Other
Universal-Direct
450.68
450.68
PREPARED BY/ DATE
Reyna Gonrales March 13, 2019
TELEPHONE
15091764-2668
A18 Effective 7/1/17 through 6/30119 REVISED 12/31118
CURR DOC NO
VCA
DOC DATE
VENDOR NO.
SWV0002426-19
AGENCY APPROVAL:
Sarah Mariani 360-725-3774 sarah.mariani hca.wa. ov,
ACCOUNTING APPROVAL FOR PAYMENT/ DATE
19 Biennium Contract
Page /
Rev 311/18