HomeMy WebLinkAbout238441 10/21/14 CITY OF CARMEL, INDIANA VENDOR: 00353199
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® zl ONE CIVIC SQUARE ERNIE MAROON CHECK AMOUNT: $***"***400.00*
f. a° CARMEL, INDIANA 46032 1004 RETFORD DR CHECK NUMBER: 238441
WESTFIELD IN 46074 CHECK DATE: 10/21/14
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400.00 HSA
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:
Ernest Maroon
1004 Retford Drive
Westfield, IN 46074
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: October 20, 2014
I
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City FormNo.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
Ernest Maroon
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
10 90 14 10 90 14 Savings Aeeeunt Ineenfive $400.00
Total $400.00
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accor-
dance with IC 5-11-10-1.6.
, 20
Clerk-Treasurer
VOUCHER Ngoaau44 WARRANT NO.
ALLOWED 20
est MSIFeen IN SUM OF $
1004 Retford Drive
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 bill(s) is (are) true and correct and that
10.20.14 301 $400.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund