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SNOHOMISH COUNTY <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 I i sted herein are proper <br /> charges for materials, merchandise, or services furnished to Snohomish County, and that di goods furnished and/or <br /> services rendered have been provided without di scri mi nati on on the grounds of race, creed, national origin, haidi cap, <br /> seat, or age. <br /> AUTHORIZING SIGNATURE: DATE: <br /> Voucher Invoice Total Charged To: <br /> Check# Vendor Refer.# Description Amount Non-Grant Grant <br /> (UseAdditional Pages as Necessary) Total: $ - $ - $ - <br /> Exhibit D <br /> HCS-21-80-04-198 <br /> City of Everett <br /> Page 2 of 2 <br />