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venao,'s c-f-te. hereoy certify under penalty or pefu t the items and mels bled herein proper charas: for materials, mamhanmss
Washington, and mal all goods lumished env« s. r�ryd-sietl haw leen ovidad w;mwt di nminalan nacauas a Z. sae, mental
nanaicap, religion. «viemam era «aisaeled valxan lis.
«saM ss rumishatl to the state or
slams, we. used, caor, national origin.
Health Caro Authority
PO Box 42691
O m ia, WA 98504-2691
BC
Grant County
(iiiii
840 E Plub Street
Yn
Moses Lala, WA 98837
(titre)
_
(di a)
TAX IDENTIFICATION NUMBER
91-6001319
MONTH/YEAR OF SERVICE IRECEIVED
- -
BY
DATE RECEIVED
BARB PMOeaY IldT1YRY MNIIE
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11.1 Admin
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297.'',,
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1.22025
21 Can unity -Based Coatlination-Pa
Commly-Based Process
Universa6lndiect
22.5 Commundy Coalition Coordinator
Communityasead Process
Universal-D'racl
0 W
2205 Community Coalition
Comm-hy-Sased Process
UnheroaFOkect
000
22.5.1 Community Coalition Coordinator- ME
Community -Based Process
Unlwr88FDkecl
7,042.82
7,042.82
22.5.1 Community Coalillon -ME
Community -Based Process
Universa4Dkecl
0.00
0.00
22.7.1 Tisees-enssRea-es-sowtn nwess --tt Omer
Unimsal-Direct
- 3B
3,714.48
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
22.5.1 CommunityCoaFion Coordinator -Quincy
Commun"ased Process
Universai-0irecl
1 307 76
134711
2,755.17
22.5.1 Canmulity Coalition- Member Window Clog- Quincy CommundyBaaed Process
Univer-kMact
0.00
0.00
0.00
0.00
0.00
22,2,1 Sk"Itlening Familles-SprkV 2020/supptiea-Quincy Education
Universal -Direct
316 75
316.75
22.2.1 SPORT PPW - Quincy
Education
Universal -Direct
t+8700
1,/97.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
7,04282 581.58 0.00
11412.38 3,714.48 0.001 297.16 0.00 1
3,198.05 0.00
1024W
PREPARED BYI DATE
Rayne 0-1- 4123/2020
TELEPHONE
- 509764.2660
A19 Effective 711119 through 6130121 REVISED 7118119
CURR DOC NO
I DOC DATE
VENDOR NO.AGENCY
APPROVAL:
Sarah Marlani 360.725-9401 Sarah.Mariani hca.Wa. OV
ACCOUNTING APPROVAL FOR PAYMENTI DATE
Z l I Biennium Con- pegs 1 Rn 7.140