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FORM - • STATE OF WASHINGTON AGENCY USE ONLY <br /> - - <br /> Al9-1A AGENCY NO, CONTRACT Na OR GA AUTH.NO. <br /> INVOICE VOUCHER 103 FY18-61018-003 <br /> _ AGENCY-NAME - INSTRUCTIONS TO VENDOR OR CLAIMANT: <br /> _Department of Archaeology and Historic Preservation In ihe'absence+f a duailcd invoic0,submit this form to claim payment for <br /> PO Box 48343 materials,merchandise or services. Show complete detail for each item, <br /> 1063 South Capital Way Suite <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 /> VENDOR OR CLAIMANT(warrant is to be pa fable to) 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 /> 3002 Wetmore Street creed,color,national origin,handicap,religion,or Vietnam era or disabled <br /> Everett, WA 98201 veteran status. <br /> . By: - . - <br /> __ _-... . .. (Sign in ink) <br /> Attachment Four <br /> -- (Title) (Date) <br /> FEDERAL LD,NO.OR SOCIAL SECURITY NO_ RECEIVED BY - DATE RECEIVED <br /> DATE I DESCRIPTION QUANTITY UNIT PRICE AMOUNT <br /> PREPARED BY(Fiscal) DATE DIVISION APPROVAL DATE <br /> DOC-DATE— ICURRENT 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 /> ; <br /> APPROVED FOR PAYMENT BY FISCAL DATE WARRANT TOTAL <br /> Approved CTED Form A19-1A (10/15/95) 1 51 <br />