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16 <br /> FORM STATE OF WASHINGTONAGENCY USE ONLY <br /> A19-1A _ AGENCY NO- _.... CONTRACT NO OR GA AUTH.NO. <br /> INVOICE VOUCHER 103 FY14-61014-004 <br /> AGENCY NAME _ IN$TRUGT!ONS 'O.VENDOR OR CLAIMANT :_ <br /> Department of Archaeology and Historic Preservation In the absence.of a:detailed invoice,submit this form to claim payment for <br /> PO Box 46343 materials,merchandise or services. Show complete detail for each item. <br /> 1063 South Capital Way Suite <br /> Olympia,Wa 96504-8343 Vendor's Certificate: <br /> I hereby certify under penalty of perjury that the items and totals listed herein <br /> ATTN: are proper charges for materials,merchandise or services furnished to the <br /> ..VENDOR OR CLAIMANT(warrant is to be payable to) State of Washington,and that all goods furnished and/or services rendered have <br /> Cityof Everett been provided without discrimination because of age,sex,marital status,race, <br /> creed,color,national origin,handicap,religion,or Vietnam era or disabled <br /> 3002 Westmore Street veteran status. <br /> Everett, WA 98201 • <br /> By: <br /> (Sign iri <br /> Attachement Four - , . <br /> (Title) (Date) ry <br /> —' <br /> `, RECEIVED- BY"' ' "" RECEIBY DATE RECEIVED <br /> DATE DESCRIPTION QUANTITY UNIT PRICE _, AMOUNT <br /> 'PREPARED BY(Fiscal) <br /> DATE DIVISION APPROVAL DATE <br /> - <br /> DOC DATE CURRENT DOC NO REF DOC NO VENDOR NUMBER - • VENDOR MESSAGE <br /> SUB ..._ <br /> TRANS 0 • APPN PROGRAM SUB SUB INVOICE GENERAL <br /> SUP CODE D FUND INDEX INDEX OBJ OBJ CNTY CITY PROJECT AMOUNT NUMBER LEDGER <br /> y . <br /> `APPROVED FOR PAYMENT BY FISCAL DATE WARRANT TOTAL <br /> Approved CTED Form A19-1A (10/15/95) 1 13 <br />