230521 03/26/14 (9,
CITY OF CARMEL, INDIANA VENDOR: 362732
ONE CIVIC SQUARE PAMELA LISTER CHECK AMOUNT: $ ... "50.96*
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK NUMBER: 230521
CARMEL IN 46032 CHECK DATE: 03/26/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 50.96 TRAVEL PER DIEMS
Prescribed by State Board of Accounts General Form No.101 (1955)
MILEAGE CLAIM
Governments nit
On Account of Appropriation No. q36 -6! for , fetal
tvalce,Mardi Department or InstituffonT
`DATE FROM TO
ODOMETER READING" NATURE OF BUSINESS AUTO MILES MILEAGE @
20/7 Point Point Start Finish TRAVELED PER MILE
J41?
a0 �t k 3
311_1q e, , , L4_ q —3 �
3
—/ v, lzl7S"ao 17 3 9�
/7-! ,
if
ILL
Auto License No. TOTALS f (�
" SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155,Acts 1953, I,hereby certify that the foregoing account is just and correct, that the amount claimed ' ally due, after
allowing all just credits, and that no part of the same has been paid.
Date '�� ' / /
Claim No. Warrant No. I hcrve examined the within,claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
Th duly auth ed as r
That it is ul enticat egtti
- -- — by law;
That it is based upon statutory authoForrr
That it is apparently , {in or�rect
On Account of Appropriation No:,q_k _(� - for _
Disbursing pi8cer
Y Allowed 20
in the sum of$
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(Board or Commission)
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(Oflicicd Title)
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