Form Driver Form 4 Driver Form 4 Washington State Tax Invoice Voucher

_{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