HomeMy WebLinkAbout234459 07/08/14 ^�� CITY OF CARMEL, INDIANA VENDOR: 00351588
• ONE CIVIC SQUARE RICHARD DUFEK CHECK AMOUNT: $*******400.00*
s. _� CARMEL, INDIANA 46032 850 HADLEIGH PASS CHECK NUMBER: 234459
9M�[t0 �' WESTFIELD IN 46074 CHECK DATE: 07/08/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400.00 HSA INCENTIVE
City of Carmel Employee Health Benefit Plan
Health Savings Account Incentive
The retired plan participant listed below has elected Plan A for 2014 and is eligible for a bi-
annual contribution to his or her HSA account, as authorized by Resolution BPW-10-03-12-02.
Please return check to Human Resources for further processing
Plan Participant/Payee:
Richard Dufek
850 Hadleigh Pass
Westfield,IN 46074
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: July 7,2014
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Richard Dufek
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
07/197/14—07.07.14 Health Sav8ngs Account Incentmi-te $40000
Total $400.00
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5-11-10-1.6.
, 20—
Clerk-Treasurer
20Clerk-Treasurer
VOUCHER N007474 WARRANT NO. �
ALLOWED 20
Richard Dufek IN SUM OF $
850 Hadleigh Pass
Westfield, IN 46074
$ $400.00
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
Board Members
Po#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
i bill(s) is (are) true and correct and that the
07.07.14 301 $400.00 materials or services itemized thereon for
which charge is made were ordered and
received except
I
4
I
I
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
I