Form State of AGENCY USE ONLY AGENCY NO. P.O. OR A19-1A INVOICE VOUCHER LOCATION CODE AUTH. NO. (Rev. 5/91) 303 AGENCY NAME INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to DOH Contracts Grants Management – claim payment for materials, merchandise or services. Show complete detail for each item. VENDOR OR CLAIMANT (Warrant is to be payable to) I hereby certify under penalty of perjury that the Vendor’s Certificate. 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, Benton-Franklin Health District color, national origin, handicap, religion, or Vietnam era or disabled 7102 W. Okanogan Place veterans status Kennewick, WA 99336 BY____________________________________________ (SIGN IN INK) _______________________________________________________ (TITLE) (DATE) Received By Date Federal ID No. or Social Security No. (For Reporting Personal Services Contract Payments to I.R.S.) Received Reimbursement for services under contract #: CLH18237 DATE DESCRIPTION QUANTITY UNIT UNIT AMOUNT FOR PRICE AGENCY USE 2018-2020 Consolidated Contract Billing for the Month of: ______________ Prepared by Telephone Number Date Agency Approval Date Doc. Date Pmt Due Date Current Doc No. Ref. Doc No. Vendor Number Vendor Message CLH18237 SWV0008939-02 County Work City/ Class Town MASTER INDEX Sub Ref M Sub Budget Trans Org Sub Proj Sub Amount Invoice Number Alloc MOS Project Fund - Appn - P.I. Doc O Obj Unit Code Index Proj Phas Obj Suf D NB Grants Approval for Payment Date Warrant Total Invoice No
Form A19-1A (Rev. 5/91) State of INVOICE VOUCHER AGENCY NO. 303 AGENCY USE ONLY LOCATION CODE P.O. OR AUTH. NO. AGENCY NAME DOH Contracts – Grants Management INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claim payment for materials, merchandise or services. Show complete detail for each item. VENDOR OR CLAIMANT (Warrant is to be payable to) Benton-Franklin Health District 7102 W. Okanogan Place Kennewick, WA 99336 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, national origin, handicap, religion, or Vietnam era or disabled veterans status BY____________________________________________ (SIGN IN INK) _______________________________________________________ (TITLE) (DATE) Federal ID No. or Social Security No. (For Reporting Personal Services Contract Payments to I.R.S.) Reimbursement for services under contract #: CLH18237 Received By Date Received DATE DESCRIPTION QUANTITY UNIT UNIT PRICE AMOUNT FOR AGENCY USE 2018-2020 Consolidated Contract Billing for the Month of: ______________ Prepared by Telephone Number Date Agency Approval Date Doc. Date Pmt Due Date Current Doc No. Ref. Doc No. CLH18237 Vendor Number SWV0008939-02 Vendor Message Work Class County City/ Town Ref Doc Suf Trans Code M O D MASTER INDEX Fund - Appn - P.I. Sub Obj Sub Sub Obj Org Index Alloc Budget Unit MOS Project Sub Proj Proj Phas Amount Invoice Number NB Grants Approval for Payment Date Warrant Total Invoice No
A19-BentonFranklin.docx