2012-2014 Consolidated Contract A19-1A Invoice Voucher - DOC by CX9Qm392


									        Form                                      State of Washington                                                                              AGENCY USE ONLY
      A19-1A                                                                                                           AGENCY NO.                                                P.O. OR
      (Rev. 5/91)
                                            INVOICE VOUCHER                                                                                         LOCATION CODE               AUTH. NO.

                                  AGENCY NAME
                                                                                                                    INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to
DOH Contracts – Grants Management                                                                                   claim payment for materials, merchandise or services. Show
PO Box 47905                                                                                                        complete detail for each item.
Olympia, WA 98504-7905
              VENDOR OR CLAIMANT                  (Warrant is to be payable to)
                                                                                                                    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,
        Mason County Public Health                                                                                  color, national origin, handicap, religion, or Vietnam era or disabled
        PO Box 1666                                                                                                 veterans status
        Shelton, WA 98584                                                                                           BY____________________________________________
                                                                                                                                            (SIGN IN INK)

                                                                                                                                      (TITLE)                       (DATE)
Federal ID No. or Social Security No. (For Reporting Personal Services Contract Payments to I.R.S.)                 Received By                                            Date
        Reimbursement for services under contract #: C16893
      DATE                                  DESCRIPTION                                          QUANTITY             UNIT         UNIT               AMOUNT                  FOR
                                                                                                                                  PRICE                                      AGENCY

                    2012-2014 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
                                                                    C1689300                     SWV000189304
                                                                                         Work    County     City/
                                                                                         Class              Town

                    M       MASTER INDEX                   Sub
                                                                              Org                Budget                          Sub     Proj
Doc                 O        Fund - Appn - P.I.                      Sub                 Alloc              MOS        Project                          Amount              Invoice Number
           Code                                            Obj               Index                Unit                           Proj   Phas
Suf                 D                                                Obj

Grants Approval for Payment                                                                          Date                                       Warrant Total              Invoice No

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