HomeMy WebLinkAboutGrant Related - GRISFaaam STATE OF WASHINGTON
A19 -1A INVOICE VOUCHER
(REV. sro1)
WA State Healthcare Authority
PO Box 42691
Olympia, WA 98504-5500
Grant County
dba Grant Integrated Health
840 E Plum Street
AGENCY USE ONLY ;
AGENCYCONTRACT,#
INVOICE #
1070
1
K3376
INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claim payment
for materials, merchandise or services. Show complete detail for each item.
Vendor's Certificate. I hereby certify under penalty of perjury that the items and totals listed
herein are proper charges for materials, merchandise or services furnished to the State of
Washington, and that all goods furnished and/or services rendered have been provided
without discrimIrAption bec use of age, sex, marital status, race, creed, color, n i nal origin,
,han �Hgo`r�Cie era or dim bled yett rens status.
06/26-06/25/19 Participated in Supportive Housing Fidelity Review 5,000.00
10/15-10/16/19 Participated in Supportive Housing Fidelity Review 5,000.00
ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NO.
5,000.00
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INVOICE #
TOTAL PAYMENT
10,000.00
.PREPARED BY
TELEPHONE NUMBER
DATE
AGENCY APPROVAL
DATE
rX
_
Y•
Lisa Bennett -Perry -360-725-1961
ett Perry
DOC DAT5
PMT DUE DATE
CURRENT DOC NUMBER
REF DOC #
VENDOR #
VENDOR MESSAGE
VCA
SWV0002426-11
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MASTER INDEX
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INDEX.
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PROJECT
PROD.
f?HAS
. ,
AGREEMENT ID
AMOUNT ; •;
' NU1v1BER
001
CA* C1633
CZ 2000
C795
201 *
CBP9
62
00
K3376
5,000.00
001
ICA* I C1625
CZ I Z000
C795
201 *
CBP9
61
00
K3376
0.00
ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NO.
5,000.00
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