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CITY OF CARMEL, INDIANA VENDOR: 368729
® , ONE CIVIC SQUARE MICHAEL NASH CHECK AMOUNT: $*******296.90*
CARMEL, INDIANA 46032 4340 FARMINGTON RD CHECK NUMBER: 238018
GAS CITY IN 46933 CHECK DATE: 10/09/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 296.90 REFUND-AMBUL SERVICE
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CI'I"Y 0 ARNIEL
JAMES BRAINARD, MAYOR
October 6, 2014
Mr. Michael Nash
4340 Farmington Rd
Gas City,IN 46933-1250
RE: INVOICE#20143294:1/D.O.S. 07/04/2014
Dear Mr. Michael Nash:
Enclosed you will find a reimbursement check in the amount of$296.90.
On July 24, 2014 we received your payment for$ 296.90 check# 7300.
On September 4, 2014 we received a payment from Liberty Mutual.
Liberty Mutual paid your daughter's worker's compensation claim $396.90.
If you have any questions,please feel free to contact me at(3 17) 571-2604.
Sincerely,
. A -
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. CouTs HEADQuARTERs
Two Crvic SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
CAOMIL CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL, IN 46032-7543
(317) 5712604 Federal ID#356000972
Patient Name: NASH,ASHLEA
ASHLEA NASH CARMEL FIRE DEPARTMENT
ATTN MICHAEL NASH 2 CIVIC SQUARE
4340 FARMINGTON RD CARMEL, IN 46032-7543
GAS CITY , IN 46933
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 10/06/14 990107460
Ticket# : 20143294:1
Date of Service: 7/4/2014
DETACH HERE
MR. NASH PAID $296.90 ON JULY 24 ,2014.
CLAIM REPROCESSED WITH LIBERTY MUTUAL WORKER'S COMPENSATION PAID$396.90.
REFUNDING $296.90
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20143294:1
Online Payment will charge a service fee.
DateroService Deri�pt Patient Name ! Charge(s) Date, Payt(s)
Charges
7/4/2014 *BASIC LIFE SUP NASH, ASHLEA $375.00
7/4/2014 *MILEAGE NASH, ASHLEA $21.90
---------------------------------
Charge Total: $396.90
-Payments
Paid By: Invoice 07/04/14 $396.90
Paid By. NASH, ASHLEA Payment 07/24/14 ($296.90)
Paid By. LIBERTY MUTUAL/7205 COMMERCIAL INSURANCE 09/04/14 ($396.90)
Paid By. NASH, ASHLEA REFUND 10/06/14 $296.90
BALANCE $0.00
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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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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 NO. WARRANT NO.
ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
i
Board Members
PO#or
DEPT.# INVOICE NO. ACCT#/TITLE AMOUNT I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
RtC 29%
i
i
a
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund