Dept of Archaeology and Historic Preservation 10/4/2016

FORM STATE OF WASHINGTON AGENCY USE ONLY A19-1A AGENCY NO. CONTRACT NO.OR GA AUTH.NO. INVOICE VOUCHER 103 FY17-61017-004 AGENCY NAME INSTRUCTIONS TO VENDOR OR CLAIMANT: Department of Archaeology and Historic Preservation In the absence of a detailed invoice,submit this form to claim payment for PO Box 48343 materials,merchandise or services, Show complete detail for each item. 1110 South Capital Way Suite 30 Olympia,Wa 98504-8343 Vendor's Certificate: I hereby certify under penalty of perjury that the items and totals listed herein ATTN are proper charges for materials,merchandise or services furnished to the VENDOR OR CLAIMANT(warrant is to be payable to) State of Washington,and that all goods furnished and/or services rendered have City of Everett been provided without discrimination because of age,sex,marital status,race, Attn: Paul Popelka creed,color,national origin,handicap,religion,or Vietnam era or disabled 2930 Wetmore Ave Suite 8-A veteran status. Everett, WA 98201 By: (Sign in ink) Attachment Four (Title) (Date) FEDERAL I D NO OR SOCIAL SECURITY NO RECEIVED BY DATE RECEIVED DATE DESCRIPTION QUANTITY UNIT PRICE AMOUNT PREPARED BY(Fiscal) DATE DIVISION APPROVAL DATE DOC DATE CURRENT DOC NO REF DOC NO VENDOR NUMBER VENDOR MESSAGE M SUB TRANS 0 APPN PROGRAM SUB SUB INVOICE GENERAL SUF CODE D FUND INDEX INDEX OW OBJ CNTY CITY PROJECT AMOUNT NUMBER LEDGER APPROVED FOR PAYMENT BY FISCAL DATE WARRANT TOTAL Approved CTED Form A19-1A (10/15/95)