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( FORM STATE OF WASHINGTON x &,( f 4 , <br /> M9-1A <br /> INVOICE VOUCHER 103 FY10-61020-005 <br /> c'`.:eu,11F4 <br /> Department of Archaeology&Historic Preservation In the absence of a detailed invoice,submit this form to claim payment for <br /> 1063 S Capitol Way Suite 106 materials,merchandise or services. Show complete detail for each item. <br /> PO Box 48343 <br /> Olympia,WA 98504 8343 Vendor's Certificate: <br /> I hereby certify under penalty of perjury that the items and totals listed herein <br /> ATTN: are proper charges for materials,merchandise or services furnished to the <br /> �( R� ;'4y2 ;, O ,`:_ a °,P`Q State of Washington,and that all goods furnished and/or services rendered have <br /> City of Everett been provided without discrimination because of age,sex,marital status,race, <br /> Planning creed,color,national origin,handicap,religion,or Vietnam era or disabled <br /> veteran status. <br /> 3002 Wetmore Street <br /> Everett,WA 98201 <br /> By: <br /> (Sign in ink) <br /> ATTACHMENT NUMBER 4 <br /> (Title) (Date) <br /> FEDERAL I.D.NO.OR SOCIAL SECURITY NO. RECEIVED BY DATE RECEIVED <br /> br .. :. e } , .. ,.... ..• ._.. <br /> PREPARED BY(Fiscal) DATE DIVISION APPROVAL DATE <br /> DOC DATE CURRENT DOC NO REF DOC NO VENDOR NUMBER VENDOR MESSAGE <br /> M SUB <br /> TRANS 0 APPN PROGRAM SUB SUB INVOICE GENERAL. <br /> SUF CODE D FUND INDEX INDEX OBJ OBJ CNTY CITY PROJECT AMOUNT NUMBER LEDGER <br /> APPROVED FOR PAYMENT BY FISCAL DATE WARRANT TOTAL <br /> 66 <br /> Approved CTED Form A19-1A (10/15/95) <br />