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SNOHOMISH COUNTY 44+ <br /> HUMAN SERVICES DEPARTM ENT <br /> 3000 RO C K E F E L L E R,MIS 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 f urni shed to Snohomish County,and that all goods f urni shed and/or <br /> services rendered have been provided without discrimination on the grounds of race,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-1 <br /> BH-20-62-06-198(1) <br /> City of Everett <br /> Page 2 of 2 <br />