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SNOHOMISH COUNTY <br /> HUMAN SERVICES DEPARTMENT <br /> 3000 ROCKEFELLER AVENUE, M/S 305 <br /> EVERETT, WA 98201 <br /> AGENCY CERTIFICATION FORM <br /> Agency Certification: I hereby certify under penalty of perjury that the items and totals listed herein are <br /> proper charges for materials, merchandise, or services furnished to Snohomish County, and that all goods <br /> furnished and/or services rendered have been provided without discrimination on the grounds of race, creed, <br /> national origin, handicap, sex, or age. <br /> AUTHORIZING SIGNATURE: DATE: <br /> (sign in ink) <br /> Voucher Invoice Total Charged To: <br /> Check# Vendor Refer.# Description Amount Non-Grant Grant <br /> (Use Additional Pages as Necessary) Total: <br /> Exhibit D <br /> HCS-18-70-1803-198 <br /> City of Everett <br /> Page 2 of 2 <br />