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1 1 1 t-► V L Y. 1 lir 1'Z ll 1..4 'U 4141.01...1 'V ``r I-1 <br /> _l l.r 1"' • <br /> LeJj CITY OF EVERETT <br /> YOUR <br /> DATE PREPARED CLAIMANT VENDOR NUMBER <br /> AUTHORITY PERIOD THRU <br /> TRAIN MEALS AUTO MISCELLANEOUS <br /> DATE PLANE LODGING BREAK TOTAL PURPOSE / EXPLANATION <br /> BUS FAST LUNCH DINNER MILES AMOUNT ITEM AMOUNT <br /> 1 16 <br /> ti 2 17 <br /> 3 18 <br /> LU 4 19 <br /> 5 20 <br /> N 6 21 <br /> 7 22 <br /> Z 8 23 <br /> 9 24 <br /> w 10 25 <br /> 11 26 <br /> a 12 27 <br /> 13 28 <br /> X 14 29 <br /> 15 30 <br /> LU 31 <br /> TOTAL AMOUNT DUE CLAIMANT <br /> BUDGET ACCOUNT <br /> FUND BASUB ELEM UTIL OBJ PROG. W/O AMOUNT <br /> IMPORTANT NOTE: <br /> ATTACH VEHICLE LOG ATTACH ALL <br /> IF MILEAGE CLAIMED APPLICABLE RECEIPTS <br /> • <br /> I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THIS IS A TRUE DATE <br /> AND CORRECT CLAIM FOR NECESSARY EXPENSES INCURRED BY ME AND CERTIFICATION FOR PAYMENT <br /> THAT NO PAYMENT HAS BEEN RECEIVED BY ME ON ACCOUNT THEREOF. SUPERVISOR I, THE UNDERSIGNED, DO HEREBY CERTIFY UNDER PENALTY OF PERJURY <br /> THAT THE MATERIALS HAVE BEEN FURNISHED, THE SERVICES RENDEREL <br /> OR THE LABOR PERFORMED AS DESCRIBED HEREIN,AND THAT THE CLAM' <br /> DEPT.HEAD IS A JUST, DUE AND UNPAID OBLIGATION AGAINST THE CITY OF EVERET1 <br /> AND THAT I AM AUTHORIZED TO AUTHENTICATE AND CERTIFY TO SAI[ <br /> CLAIM. <br /> CLAIMANT SIGNATURE MAYOR <br /> TITLE J� COUNCIL PRESIDENT <br /> CITY CLERK <br /> CITY CLERK 514.413 <br />