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SNOHOM I SH COUNTY J'. <br /> HUMAN SERVICES DEPARTMENT <br /> 3000 ROCKEFELLER,M/S 305 <br /> EVERETT,WA 98201 <br /> AGENCY CERTIFICATION FORM <br /> Agency Certification: I hereby certify under penalty of perjury that the items and totals listed herein are proper <br /> charges for materials, merchandise,or services furnished to Snohomish County,and that all goods f urni shed and/or <br /> services rendered have been provided without discrimination on the grounds of rxp, creed, national origin, handicap, <br /> sex, or age. <br /> AUTHORIZING SIGNATURE: DATE: <br /> Voucher Invoice Total Charged To: <br /> Check# Vendor Refer.# Description Amount Non-Grant Grant <br /> (Use Additional Pages as Necessary) Total: $ - $ - $ - <br /> Exhibit D <br /> BH-20-62-06-198 <br /> City of Everett <br /> Page 2 of 2 <br />