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<br />, <br /> <br />tr <br />. <br />\ <br /> <br />. <br /> <br />~' <br /> <br />~I <br />l <br />HALL COll"NTY VENDOR CLAIM FORM <br /> <br />lA <br /> <br />DATE DESCRIPTION <br /> <br />AMOUNT <br /> <br />MAILSTUB WI WARRANT <br /> <br />, <br /> <br />DJESEL TAX <br /> <br />$1,113.00 <br /> <br />January 11. 2004 <br /> <br />WARRANT & CLAIM NO. <br /> <br />$1,113.00 <br /> <br />LINE iTEM# 218.02 $1,113.00 <br />LINE ITEM# <br />LINE JTEM# <br />LINE iTEM# <br />LINE ITEM# <br />LINE iTEM# <br />LINE ITEM# <br />LINE ITEM # <br />LINE ITEM# <br />LINE ITEM# <br />LINE ITEM# <br />LINE ITEM# <br /> $1,113.00 <br /> <br />PAYABLE TO: <br /> <br />Motor Fuels Division <br /> <br />P.O. Box 98904 <br /> <br />Lincoln, NE 68509-8904 <br /> <br />AMOUNT$ $1.113.00 <br /> <br />,. <br /> <br />AGAmST HALL COUNTY <br /> <br />FOR: Diesel Tax <br /> <br />---~ ------------------------------------- --------------------- <br /> <br />J do solemnly swear that the above account is just and true <br />and th at neither the same nor any part thereof h as been paid. <br /> <br />HIGHWAY <br />DEPARTMENT <br /> <br />PAYABLE TO: <br /> <br />APPROVED BY <br /> <br />Audited and allowed by the County board, witb the Clerk ordered <br />to issue a warrant in payment of lhi So claim on the <br /> <br />.. --------------- ------- --- --.. --- -- --- --- --- ---- ----..... <br /> <br />,~~1,,~ <br /> <br />ROAD <br /> <br />FUND <br /> <br />By:-m---____________________,_____m________________________ <br /> <br />I <br /> <br />PAID ON WARRANT N( <br /> <br />~ <br />