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SNOHOMISH COUNTY <br />HUMAN SERVICESDEPARTMENT <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 isted hero n are proper <br />charges for materials, merchandise, or services furnished to Snohomish County, and that all goods furnished and/or <br />services rendered have been provided without di scri mi nation on the grounds of race, creed, national on gi n, handi cap, <br />sex, or age. <br />AUTHORIZING SIGNATURE: <br />DATE: <br />Voucher <br />Check # <br />Vendor <br />Invoice <br />Refer. # <br />Description <br />Total <br />Amount <br />Charged <br />Non -Grant <br />To: <br />Grant <br />(Use Additional Pages as Necessary) <br />Total: <br />Exhibit D <br />BH-22-62-06-198 <br />City of Everett <br />Page 2 of 2 <br />