1996, 01-16 Permit: 96000154 Overage RefundVendor Contact/Tel
LGFS PAYMENT DOCUMENT
SPOKANE COUNTY AUDITOR
Corditrr®p Order
stir
Change Order #_
Bid ID
Blanket#
RC#
VI#
FOB: PO DATE: BLDG/ROOM: BUYER
ACCTG. PERIOD: DELIVERY DATE: WAREHOUSE:
COMMENTS- PNTF.RFn RY- PURCHASING DIRECTOR -
COMM LN# DESCRIPTION
COMMODITY NO REF ACCT LINE QUANTITY UNIT UNIT PRICE TOTAL PRICE
14621 E OLYMPIC AVENUF
PAGE T'3TAL: 10, ..
LISCOUNT TOTAL: 04
FREIGHT TOTAL' �.
SALES TAX TOTAL: 30
?JRCHASE ;ROER VALUE: 13.
TAX T3TA ' C.
Jt=KAN1) TOT
LINE NO. FUND AGCY _1ORG _ _ SB ORG _ ACT OBI SB OBI REV SRC SB REV I RPT CAT BS ACCT JOB NO. PAX THIS AMOUNT P/F
RECEIVING CERTIFICATION
Materials noted in quantity J have been
received in good condition or contracted for.
SIGNED ^ r'
TITLE OA 4
DATE 1/16/ -
PAYMENT
/16/
PAYMENT CERTIFICATION
TRAVEL CERTIFICATION
1, the undersigned do hereby certify under penalty of perjury that sufficient funds have been budgeted for this claim, the
1 hereby certify under penalty of perjury that this
materials have been furnished, services rendered or labor performed as described herein or contracted for, that the claim is
is a true and correct claim for necessary expenses
a just, due and unpaid obligation against Spokane County or fund agency indicated above, that I am authorized to authenticate
incurred by me and that no payment has been received
and certify to said claim.
by me on account thereof.
SIGNED TITLE y ICE ADM I N I STREP, I'- R SIGNED TITLE
DEPARTMENT2
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