HomeMy WebLinkAboutReimbursable Work Request - BOCCForm State of Washington
A19 -1A - INVOICE VOUCHER
( Rev. 5/91)
Agency Use Only
Agency Location Code P.R. or
No. Auth. No.
AGENCY NAME
Grant County Health District
1038 W Ivy Ave
INSTRUCTIONS TO VENDOR OR CLAIMANT:
Submit this form to claim payment for materials, merchandise or services. Show complete
Moses Lake, WA 98837
detail for each item.
Vendor's Certificate: I hereby certify under penalty of perjury that the items and totals
VENDOR OR CLAIMANT (Warrant is to be payable to)
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 discrimination because of age, sex, marital status, race, creed, color,
Grant Count
national origin, handicap, religion, or Vietnam era or disabled veterans status.
y
840 E. Plum St.
(Signature)
Moses Lake, WA 98837
By o2
BOCC Chair
(Title) (Date)
Month: March 2019
Amount
Salaries
Benefits
Goods & Services:
$9,000.00
Indirect Costs
Total:
$9,000.00
Prepared by
Date
Agency Approval
Date
Reyna Gonzales
6/3/2019