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State of Washington
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1070 1763-94250
A19-IA
Invoice Voucher
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Health Care Authority
PO BOX 42691
Olympia WA 98504
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 furnished
all goods and/or services rendered have been provided without discrimination because of age, sex, marital status, race,
creed, color, national origin, handicap, Vietnam
religion, or era or disabled veterans status.
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Grant County
BY
840 E Plum Street
Moses Lake, WA 98837
BOC C Chair (sign in ink)
(title) 1
(date)
TAX IDENTIFICATION NUMBER
MONTH OF SERVICE RECEIVED BY DATE RECEIVED
Mach 2019
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�vEN _ General �
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223 26 � 20.67 316.13 1,070.89
21 Community-Based Coordination-Px
Community-Based Process Universal-Indirect tt
22.5 Community Coalition Coordinator
Community-Based Process Universal-Direct
22.5 Community Coalition
Community-Based Process Universal-Direct _
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22.5.1 Community Coalition Coordinator - ML
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Community-Based Process Universal-Direct 5,427 69 258.31
22.5.1 Community Coalition - ML
5,686.00
Community-Based Process Universal-Direct _
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22.5.1 Community Coalition Coordinator -Quincy
Community-Based Process Universal-Direct 2,790.78 3,951.65
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22.5.1 Community Coalition - Quincy
6,742.43
Community-Based Process Universal-Direct
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13;014 04t�78 98,E (3;4992`
PREPARED BY/ DATE
TELEPHONE - - - -- _
Reyna Gonzales June 24th, 2019
_
(509) 764-2660 A19: Effective 711117 through 6130/'19. , REVISED 12/31118
CURR DOC NO
DOC DATE VENDOR NO. AGENCY APPROVAL:
VCA
SVVV0002426-19 Sarah Mariani 360-725-3774 sarah.mariani@hca.wa.gov
ACCOUNTING APPROVAL FOR PAYMENT/ DATE
19 Biennium Contract
Page 1 Rev 3/1118