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HomeMy WebLinkAboutInvoices - Central ServicesFORM STATE OF WASHINGTON A 19-1A INVOICE VOUCHER (Rev. 5/91) ti\ AGENCY 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, tional origin, handicap, religion, or Viet Jeralablekran tatus. e III /1� INIOom (SSl o+� Washington State Department of Agriculture Fairs Program PO Box 42560 Olympia, WA 98504-2560 VENDOR OR CLAIMANT arrant is to be pa able to Grant County (Grant County Fair) Attn: County Treasurer PO Box 37 Ephrata, WA 98823 (TITLE) (DATE) FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S. RECEIVED BY DATE RECEIVED DATE DESCRIPTION QUANTITY UNIT PRICE AMOUNT FOR AGENCY USE INTERAGENCY AGREEMENT NO. K2926 1 45,000 45,000.00 Special Assistance Grant — Grant County Fairgrounds, Total Due $45,000.00 PREPARED BY TELEPHONE NUMBER DATE AGENCY APPROVAL DATE DOC. DATE PMT DUE DATE I CURRENT DOC, NO. REF DOC. I VENDOR 2426-40 NUMBER VENDOR MESSAGE UBI NUMBER REF TRANS DOC CODE M MASTERINDEX O FUND APPN PROGRAM INnFX INDEX SUB OBJ SUB SUB ORG INDEX WORKCLASS ALLOC COUNTY BUDGET UNIT CITYITOWN Mos PROJECT SUB PROJ PROD PHAS AMOUNT INVOICE NUMBER 057 A00 64460 ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NUMBER