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9 <br /> FORM STATE OF WASHINGTON AGENCY USE ONLY <br /> A19-1 A AGENCY NO. CONTRACT NO.OR GA AUTH.NO. <br /> INVOICE VOUCHER 103 FY06-61016-003 <br /> AGENCY NAME INSTRUCTIONS TO VENDOR OR CLAIMANT: <br /> .epartment of Archaeology and Historic Preservation In the absence of a detailed invoice,submit this form to claim payment for <br /> 0 Box 48343 materials,merchandise or services. Show complete detail for each item. <br /> 063 South Capital Way Suite <br /> Ilympia,Wa 98504-8343 Vendor's Certificate: <br /> I hereby certify under penalty of perjury that the items and totals listed herein <br /> TTN: are proper charges for materials,merchandise or services furnished to the <br /> 'ENDOR OR CLAIMANT(warrant is to be payable to) State of Washington,and that all goods furnished and/or services rendered have <br /> pity of Everett been provided without discrimination because of age,sex,marital status,race, <br /> :verett Planning creed,color,national origin,handicap,religion,or Vietnam era or disabled <br /> 002 Wetmore Street veteran status. <br /> :verett, WA 98201 <br /> By: <br /> (Sign in ink) <br /> (Title) (Date) <br /> EDERAL I.D.NO.OR SOCIAL SECURITY NO. RECEIVED BY DATE RECEIVED <br /> 1-6001248 <br /> -- 1 <br /> DATE DESCRIPTION QUANTITY UNIT PRICE AMOUNT <br /> 1EPARED BY(Fiscal) DATE DIVISION APPROVAL DATE <br /> )C DATE CURRENT DOC NO REF DOC NO VENDOR NUMBER VENDOR MESSAGE <br /> M SUB <br /> TRANS 0 APPN PROGRAM SUB SUB INVOICE GENERAL <br /> UF CODE D FUND INDEX INDEX OBJ OBJ CNTY CITY PROJECT AMOUNT NUMBER LEDGER <br /> 'PROVED FOR PAYMENT ElY FISCAL DATE WARRANT TOTAL <br /> ti 8 <br /> ,roved CTED Form A19-1A (10/15/95) <br />