239229 11/19/14 (9,
CITY OF CARMEL, INDIANA VENDOR: 355377
ONE CIVIC SQUARE LOIS CRAIG CHECK AMOUNT: S"`*""'*13.44'
CARMEL, INDIANA 46032 10680 MORRISTOWN COURT CHECK NUMBER: 239229
CARMEL IN 46032 CHECK DATE: 11/19/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1701 4343004 13.44 TRAVEL PER DIEMS
Prescribed by State Board of Accounts ` General Form No.101 (1955)
MILEAGE CLAIM
TO "No. �
DR.
h& 614 WJ
(Governmental Unit)
WdOn Account of Appropriation for �.
(Office,Board, Department or Institution)
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DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE @
20 Point Point, Start Finish TRAVELED PER MILE
74 1 -7
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Auto License No. TOTALS
* 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, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
Date
Clcdm No. Warrant No. ' I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as required
by law;
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j That it is based upon statitQiy authority;
�
gco�rr�ectI�`l� That it is apparently t
On Account of Appropria�iso/jn/)No, for
Disbursing Officer .
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Allowed 20 o
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in the sum of$ o -
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rom ¢ �.
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C- 'd O Sz
(Board or Commission)
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FILED (D
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(Official Title) ,
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