STATE OF WASHINGTON INVOICE VOUCHER
PURCHASE ORDER NO. OR TRAVEL AUTHORITY NO.
WASHINGTON STATE UNIVERSITY 365
DEPARTMENT NAME
Sleep and Performance Research Center
DEPARTMENT ADDRESS MAIL CODE
412 E. Spokane Falls Blvd.
DEPARTMENTAL CONTACT CONTACT TELEPHONE NO.
Carol Silvieus 509-358-7750
VENDOR OR CLAIMANT
INSTRUCTIONS TO VENDOR OR CLAIMANT:
Submit this form to claim payment for materials, merchandise or services. Show complete detail for each item.
VENDOR’S CERTIFICATION
I hereby certify under penalty of perjury that the items and totals listed herein are proper charges for materials, merchandise, or services furnished to the state of Washington.
NAME
Are you a U.S. citizen?
YES NO
If no, indicate visa type
ADDRESS CITY/STATE/ZIP CODE
WSU ID NUMBER (WSU EMPLOYEE/STUDENT)
SOCIAL SECURITY NO. OR EMPLOYER TAXPAYER ID NO. (NON-WSU INDIVIDUAL) *
BY: (Vendor/Claimant’s Signature in Ink) TITLE
X
* It is unlawful for any state agency to deny any right, benefit, or privilege provided by law because an individual refuses to disclose his or her social security number except in specified circumstances. WSU is requiring that
non-WSU individuals requesting payment from WSU disclose social security number or employer ID number (EIN) pursuant to Section 6109 of the Internal Revenue Code. When required, WSU will use disclosed social security numbers for IRS reporting purposes only.
DATE DESCRIPTION QUANT UNIT UNIT PRICE AMOUNT
Participant Research Fee
--Payment to Participant for Research Study (IRB #XXX)
***Please ONLY send Check to:
Attention: Carol Silvieus WSU-Spokane SPRC P.O. Box 1495
Spokane, WA 99210-1495
Each
TOTAL
DEPARTMENT:
Please sign and enter the appropriate account code.
AUTHORIZED SIGNATURE DATE TYPED/PRINTED NAME
X
FUND SUBFUND PROG
ACCOUNT CODE COMP. TAX NET INVOICE
BUDGET PROJECT OBJ SUB AMOUNT AMOUNT
WSU1273-CONTR123-0598 FMP 092904
TOTALS
File Type | application/msword |
Author | Honn, Kimberly |
Last Modified By | SYSTEM |
File Modified | 2017-10-31 |
File Created | 2017-10-31 |