Laserfiche WebLink
11 <br /> Pgt�xr.srotl s 6Lg Y4 - ' <br /> z <br /> Form State of Washington , r � ;CfA19-1A INVOICE VOUCHER <br /> 3030 GN5 N13413 <br /> INSTRUCTIONS TO VENDOR OR CLAIMANT: <br /> Mary Borges Submit this form to claim payment for materials,merchandise or services. <br /> Injury Prevention Program Show complete detail for each item. <br /> Department of Health <br /> 7211 Cleanwater Lane Bldg 11 <br /> PO Box 47832 <br /> Olympia WA 98504-7832 <br /> n.4' _tea*�,.; ',:0 <.:... .s e � , a:. <br /> Vendor's Certificate: I hereby certify under penalty of perjury that the items <br /> and totals listed herein are proper charges for materials, merchandise or <br /> Attn: Rick Robinson or Klaus Janssen services furnished to the State of Washington,and that all goods furnished <br /> Everett Fire Department and/or services rendered have been provided without discrimination because <br /> of age, sex, marital status, race, creed, color, national origin, handicap, <br /> 2 811 Oakes Ave religion,or Vietnam era or disabled veterans status. <br /> Everett WA 98201 <br /> By <br /> (Title) (Date) <br /> Federal I.D.No.or Social Security No. Received By: Date Received: <br /> (For Reporting Personal Services Contract Payments to I.R.S.) <br /> 91-6001248 <br /> Ron Tobin <br /> .. M,m � q�<%�" � `� * Vit-. � �" ��. �,„ � �" �` "':'�w '.'+." " .-. ,. <br /> Date Description Date Due Amount <br /> Monthly Report Feb 15, $1, 000 <br /> 2005 ' <br /> Monthly Report March 15, $500 <br /> 2005 <br /> Final Report August 15, $500 <br /> 2005 or <br /> before <br /> Prepared by: I Telephone Number: Date: Agency Approval: Date: <br /> Ron Tobin 360)236-3687 12/1/2004 <br /> Doc.Date Pmt Due Date Current Doc No. Ref.Doc No. Vendor Number Vendor Use UBI Number <br /> Message Tax <br /> Master Index WorkClass County CityRown <br /> Rd Trans M r a-4 . �n'1 <br /> �p �� � ,� „ '� On Index Budget a+r_. .� t • <br /> Doc Code O Index Index '",6•1 :41': g1 4 Alloc Unit MOS 'TA prft Amount Invoke Number <br /> Sul <br /> 020 €€! <br /> g ,3 vjgg' ,, <br /> Preven � <br /> Accounting Approval for Payment Date Warrant Warrant No. <br /> Total <br /> 0 <br />