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HomeMy WebLinkAboutReimbursable Work Request - Health District (002)FORM STATE OF WASHINGTON A 19-1A INVOICE VOUCHER (Rev. 5/91) 0 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 andior services rendered have been provided without discrimination because of age, sex, marital status, race, creed, color, national origin, handicap, religion, or Vietnam era or 'spd veterqns status. i V BY (SIG I Cindy Carter, BOC Chair -9 Grant County Health District 1038 W Ivy Ave Moses Lake, Wa 98837 VENDOR OR CLAIMANT arrant is to be payable to Grant Integrated Services Partnership fYouth Quincy Porout 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 Trauma -Informed School Literature- Quincy 1 74.94 04/30/2020 Conference Phone System- Quincy 1 324.25 04/30/2020 Interactive Presentation Platform- Quincy 1 299.88 Total $699.07 PREPARED BY Reyna Gonzales TELEPHONE NUMBER 509 764-2660 DATE 06/03/20 AGENCY APPROVAL DATE DOC. DATE PMT DUE DATE CURRENT DOC, NO. REF DOC. VENDOR NUMBER VENDOR MESSAGE UBI NUMBER REF TRANS DOC CODE M O FUND MASTER INDEX SUB OBJ SUB SUB ORG INDEX WORKCLASS AL�oc COUNTY BUDGET UNIT CITYITOWN MOS PROJECT SUB PROJ PROJ PHAS AMOUNT INVOICE NUMBER APPN INDEXSUEX PROGRAM ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NUMBER