WA ST ADMINSTRATIVE OFFICE OF THE COURTS 7/19/2022

FORM A 19-1A (Rev. 5/91) STATE OF WASHINGTON INVOICE VOUCHER AGENCY USE ONLY AGENCY NO. LOCATION CODE P.R. OR AUTH. NO. AGENCY NAME Office of the Administrator for the Courts INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claim payment for materials, merchandise or services. Show complete detail for each item. VENDOR OR CLAIMANT (Warrant is to be payable to) Vendor’s Certificate: I hereby certify under penalty of perjury that the items and totals listed herein are proper charges for materials, merchandise or services furnished to the State of Washington, and that all goods furnished and/or services rendered have been provided without discrimination because of age, sex, marital status, race, creed, color, national origin, handicap, religion, or Vietnam era or disabled veterans status. BY (SIGN IN INK) (TITLE) (DATE) FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For reporting Personal Services Contract Payments to I.R.S. Do not fill in. Attach a W-9 form RECEIVED BY DATE RECEIVED DATE DESCRIPTION QUANTITY UNIT PRICE AMOUNT FOR AGENCY USE PREPARED BY TELEPHONE NUMBER DATE AGENCY APPROVAL DATE DOC. DATE PMT DUE DATE CURRENT DOC. NO. REF DOC. VENDOR NUMBER VENDOR MESSAGE UBI NUMBER REF DOC SUF TRANS CODE M O D FUND MASTER INDEX SUB OBJ SUB SUB OBJECT ORG INDEX WORKCLASS COUNTY CITY/TOWN PROJECT SUB PROJ PROJ PHAS AMOUNT INVOICE NUMBER APPN INDEX PROGRAM INDEX ALLOC BUDGET UNIT MOS ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NUMBER DocuSign Envelope ID: 8CD98305-8E9E-4F6A-89A1-303E075A6920 IAA23724