HomeMy WebLinkAboutReimbursable Work Request - Health DistrictFORM # STATE OF WASHINGTON
A 19-1A INVOICE VOUCHER
(Rev. 5/91)
AGENCY USE ONLY
AGENCY NO. LOCATION CODE P.R. OR AUTH. NO.
AGENCY NAME
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 discrimination because of age,
sex, marital status, race, creed, color, national origin, handicap, religion, or
Vietnam era ord' abled veterans stat
BY r
IGN N IN
Indy Carter, BOW Chair (o_ q _dod-b
Grant County Health District
1038 W Ivy Ave
Moses Lake, Wa 98837
VENDOR OR CLAIMANT Warrant is to be payable to
Grant Integrated Services
Moses Lake HYP 365
840 E Plum St
Moses Lake, Wa 98837
(TITLE) (DATE)
FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S.
91.6001319
RECEIVED BY
DATE RECEIVED
DATE
DESCRIPTION
QUANTITY
UNIT
AMOUNT
FOR AGENCY
USE
04/30/2020
Conference Phone System- Moses Lake
1
324.25
Total
$324.25
PREPARED BY
Reyna Gonzales
TELEPHONE NUMBER
509 764-2660
DATE
06/03/20
AGENCY APPROVAL
DATE
DOC. DATE
PMT DUE DATE
I CURRENT DOC, NO.
REF DOC. VENDOR
NUMBER
VENDOR MESSAGE
UBI NUMBER
REF I
DOC
Q Ir
TRANS
CODE
M MASTER INDEX
0 FUND APPN PROGRAM
SUB
OBJ
SUB
SUB npup"INDEX
ORG
WORKCLASS
ALLOC
COUNTY
BUDGET
CITYITOWN
Mos
PROJECT
SUB
PROJ
PROD
PHAS
AMOUNT
INVOICE NUMBER
ACCOUNTING APPROVAL FOR PAYMENT
DATE
WARRANT TOTAL
WARRANT NUMBER