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BH-25-62-06-198 <br />AUTHORIZING SIGNATURE: DATE: <br />Voucher Invoice Total <br />Check # Vendor Refer. # Description Amount Non-Grant Grant <br /> <br />Total: $ - $ - $ - <br />Exhibit D <br />BH-25-62-06-198 <br />City of Everett <br />(Use Additional Pages as Necessary) <br />HUMAN SERVICES DEPARTMENT <br />3000 ROCKEFELLER, M/S 305 <br />EVERETT, WA 98201 <br />SNOHOMISH COUNTY <br />AGENCY CERTIFICATION FORM <br />Charged To: <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 furnished and/or <br />services rendered have been provided without discrimination on the grounds of race, creed, national origin, handicap, <br />sex, or age.