Washington State Department of Commerce 12/22/2017

WASHINGTON STATE DEPARTMENT OF COMMERCE AGENCY NUMBER Short Code Commerce Contract Number Form VOUCHER DISTRIBUTION A19-1A DEPARTMENT OF COMMERCE 1030 S17-790A0-136 PO BOX 42525 OLYMPIA,WA 98504-2525 VENDOR OR CLAIMANT(Warrant is to be payable to:) INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claim payment for materials,merchandise,or services. Show complete detail for each item. City of Everett Vendor's Certificate:The individual signing this voucher below warrants they have the authority to do so as 2930 Wetmore Avenue, Suite 10-A authorized and on the behalf of the entity identified in the Vendor/Client section.The individual signing below certifies under penalty of perjury that the items and totals listed herein are proper charges for materials, Everett, WA 98201 merchandise or services fumished to the State of Washington,and that all goods furnished and/or services rendered have been provided without discrimination because of age,sex,marital status,race creed,color,national origin,handicap,religion or Vietnam era or disabled veterans status. Contact Person: Elizabeth Smith Phone: (425)257-7111 Contract Period January 2, 2018 through January 2, 2020 By: REPORT PERIOD (SIGN IN BLUE INK) (TITLE) (DATE) Date DESCRIPTION Budget Previously Requested Amount of This Invoice Award Remaining Balance CERB MATCH $15,125.00 CERB GRANT $43,875.00 Totals $59,000 $0.00 $0.00 $59,000.00 Match:Year/Dollars/Coding PROGRAM APPROVAL(the mdeduel signing this voucher warrents they have the authority to sign this voucher). DATE DOC DATE CURRENT DOC.NO. REFERENCE DOC NO. VENDOR NUMBER and SUFFIX SWV0000348-00 ACCOUNT NO. ASD NUMBER VENDOR MESSAGE CERB# SUB TRANS SUB CODE MASTER INDEX SUB OBJ OBJ GL ACCT SUBSID AMOUNT INVOICE SIGNATURE OF ACCOUNTING PREPARER FOR PAYMENT DATE WARRANT TOTAL ACCOUNTING APPROVAL FOR PAYMENT DATE Prepared on 1/10/2018