HomeMy WebLinkAboutReimbursable Work Request - GRIS2009-11 Biennium Contract Page 1 Rev 7-1-09
Form n
IStateof Washi gt O
A19 -1A -.-e Voucher
on
1070 1763-94250
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Health Care A!1thorqyVendor'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
.PO Box 42691 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,
Olympiq handicap, religion, or Vietnam era or disabled veterans status.
L _� WA 98�04-2691
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. . . . .............................
Grant County Ry
840 E Plum St (sign in ink)
Moses Lake WA 98837-1874i BOCC Cha r
(title) (date)
TAX IDENTIFICATION NUMBER MONTH/YEAR OF SERVICE
91-6001319 Jun -19
RECEIVED BY DATE RECEIVED
�i-
Rod NM-E ---Z� -rP,
p 2018
11.1 Admin 510 87 181.49 487.48
1,179.84
21 Community -Based Coordination-Px Community -Based Process
Universal -Indirect
:0
_40,
0.00
22.5 Community Coalition Coordinator Community -Based Process
Universal -Direct
0.00
22.5 Community Coalition Community Based Process
Universal Direct
44
rrw
0.00
0.00
22.5.1 Community Coalition Coordinator -ML Community -Based Process
22.5.1 Community Coalition - ML Community -Based Process
Universal -Direct
Universal -Direct
6,436.51
6,436.51
0.00
22.1.1 Community Prevention Education- ML Information Dissemination
Universal -Direct
0.00
0.00
22.2.1 Positive Action- ML Education
Universal -Direct
0.00
0.00
22.2.1 Strenghening Families Program - ML Education
Universal -Direct
0.00
0.00
22.2.1 PAX Good Behavior Game- Supplies- ML Education
Universal -Direct
2,717.04
2,717.04
0.00
22.6.1 Environmental Policy- ML Environmental
Universal -Direct
0.00
0.00
22.7.1 Training -Summer Inst. Meals & Hotel- ML Other
Universal -Direct
451.70
451.70
0.00
0.00
4
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
22.5 .1 Community Coalition Coordinator - Quincy Community -Based Process
Universal -Direct
1,607.57 5,115.72
6,723.29
22.5.1 Community Coalition - Quincy Community -Based Process
Universal -Direct
0.00
22.1.1 Youth Development - Quincy Information Dissemination
Universal -Direct
0.00
22.1.1 Public Awareness- Quincy Information Dissemination
Universal -Direct
........................................
0.00
0.00
0.00
22.2.1 Middle School LikfeSkills - Quincy Education
Universal -Direct
0.00
0.00
22.2 .1 Strengthening Families Program - Quincy Education
Universal -Direct
0.00
5
0,00
22.3.1 Healthy Alternatives -Graduating Senior Night supplies -Quincy Alternatives
Universal -Direct
862.12
862.12
22.3. 1 Healthy Aftematives -Summer Movie in the Park- Bumblebee Series -Quincy cy Afternatives
Universal -Direct
115.66
115.66
22.6.1 Environmental Policy -Quincy Environmental
Universal -Direct
0.00
22.7.1 Training - Summer Inst. Meals & Hotel -Quincy Other
Universal -Direct
661.05
661.05
0.00
0.00
0.00
v `4
605 5 6 ..,_;:=6.580
PREPARED BY/ DATE
TELEPHONE
509 764-2660
A19 Effective 711/19 through 6/30/21 REVISED 7118/19
Reyna Gonzales 0812012019
CURRDOC NO
8H
DOG DATE
VENDOR NO.
VI110002426-19
AGENCY APPROVAL:
ISarah Mar iani 360-725-3774 mariase@dshs.wa.gov
ACCOUNTING APPROVAL FOR PAYMENT/ DATE
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2009-11 Biennium Contract Page 1 Rev 7-1-09