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FORM A19-1 A STATE OF WASHINGTON
INVOICE VOUCHER
Agency Name
Department of Commerce
1011 Plum Street SE
P.O. Box 42525
Olympia, WA 98504-2525
ATTN: Chuck Hunter
Vendor or Claimant
Grant County Fairgrounds
3953 Airway Drive NE
Moses Lake, WA 98837
ATTN: Tom Gaines
Project: Grant Co. Fairgrounds Lighting (Moses Lake)
AGENCY USE ONLY
AGENCY
NO.
Location
Code
CONTRACT NO. OR
GA AUTH. NO.
SHORT
CODE
1030
Architecture & Engineering
21-96633-054
S21054
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: Claimant's Certification: I hereby certify under penalty of
perjury that the items and totals listed herein are proper charges for materials,
merchandise, or services furnished under the subject contract, and that the vendors
providing these materials, merchandise, or services have been paid for same. I also
certify that all materials, merchandise, and services have been provided without
discrimination c e of ase, sex, ma tal status, race, creed, color, national origin,
handicap, religp or Vietnm era ors&bl t hn status.
1i1 1
(Sign in ink)
3o CC 0fx�;� IZo2,o
(Title) (Date)
Budget Line Item
Total Project
Budget
Amount
This Invoice
State Share
This Invoice
Cumulative
State Amount
Reimbursed
1
Architecture & Engineering
$0.00
ACCOUNT NO.
ASD NUMBER
VENDOR MESSAGE
2
Site Acquisition
$0.00
SUB
OBJ
SUB
OBJ PROJECT
SUB GL SUBSID
PROJ ACCT ACCOUNT
3
Construction
$297,541.00
307,062.31
281,300.00
NZ
4
Capitalized Equipment
$0.00
5
Construction Management
$0.00
6
Other
$0.00
7
8
SIGNATURE OF ACCOUNTING PREPARER FOR PAYMENT
DATE
9
INVOICE DATE
ACCOUNTING APPROVAL FOR PAYMENT
DATE
Total Amounts:
$297,541.00
TOTAL CONTRACTED AMOUNT: $281,300.00
' Cumulative amount should include this invoice payment. Double check your figures to ensure that you haven't exceeded the contracted amount listed above.
Program Manager
Chuck Hunter
PROGRAM APPROVAL
DATE
DOC INPUT DATE
CURRENT DOC NO.
REFERENCE DOC NO.
VENDOR NUMBER
SWV0002426-03
SUFFIX
ACCOUNT NO.
ASD NUMBER
VENDOR MESSAGE
TRANS
CODE
0 MASTER APPN
D INDEX FUND INDEX
PROGRAM
INDEX
SUB
OBJ
SUB
OBJ PROJECT
SUB GL SUBSID
PROJ ACCT ACCOUNT
AMOUNT
INVOICE
NUMBER
966CO250 057 A30
96633
NZ
966C-02
SIGNATURE OF ACCOUNTING PREPARER FOR PAYMENT
DATE
WARRANT TOTAL
INVOICE DATE
ACCOUNTING APPROVAL FOR PAYMENT
DATE
5.3-A19 061003.doc