240789 01/07/15 CITY OF CARMEL, INDIANA VENDOR: 361684
ONE CIVIC SQUARE PROFESSIONAL PSYCHOLOGICAL SERVPtMK AMOUNT: $.... `2,150.00"
CARMEL, INDIANA 46032 10293 N MERIDIAN ST CHECK NUMBER: 240789
SUITE 375 CHECK DATE: 01/07/15
INDIANAPOLIS IN 46290
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4341999 12172014 750.00 OTHER PROFESSIONAL FE
1110 R4341999 32238 1995725-PRE 1,400.00 DUTY EVAL
Services
10293 North Meridian Street, Suite 375
Indianapolis, Indiana 46290-0409
PHONE: (317) 581-2288
FAX: (317)581-2295
December 17, 2014 Invoice #12172014-CPD
Carmel Police Department Darren L. Higginbotham, Psy.D.
Attn: Assistant Chief James Barlow Tax ID # 35-1995725
3 Civic Square
Carmel, Indiana 46032
RE: Todd Robbins
INVOICE
December 2, 2014 Review employer referral documentation $150.00
Psychological Testing $150.00
Clinical Interview $150.00
Report Writing $150.00
Consult with 3rd party treatment provider and/or $150.00 j
review treatment records (if needed)
Total Amount Due $750.00
Invoice Payable Upon Receipt
PPS
Services
10293 North Meridian Street, Suite 375
Indianapolis, Indiana 46290-0409
PHONE: (317)581-2288
FAX: (317)581-2295
December 17, 2014 Invoice #12172014-PRE-CPD
Carmel Police Department Darren L. Higginbotham, Psy.D.
Attn: Assistant Chief James Barlow Tax ID # 35-1995725
3 Civic Square
Carmel, Indiana 46032
RE: Brian Babczak
DOB: 8.6.1987
William Crayner
DOB: 4.16.1985
Megan Soultz
DOB: 10.21.1987
Christopher McKay
DOB: 9.9.1976
INVOICE
December 16, 2014 (4) Pre-Employment Evaluations $350.00each
Total Amount Due $1,400.00
Invoice Payable Upon Receipt
INDIANA RETAIL TAX EXEMPT PAGE
City,of C CERTIFICATE NO.003120155 002 0 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 322
35-60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES,A/P
CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL- 1997 SHIPPING LABELS AND ANY CORRESPONDENCE.
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
9294
Prof oalond Psychol®glcd SmIcosa C@lol Police Dop@jtmont
VENDOR
SHIP 3 Civic Squam
90203 Noith Moddl2n Int, Sulto 376 TO Culol, IN 4m
Indl2n2poilo, IN &I"HO (W)574=2
CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
r QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account 43410.N
4 Each Moss for DtfiyEvalua4lon $330.00 $1,400.00
Sub TotW: $1,400.00
o(n) � a
Ga�>fl Xtra Testing 0 \�
Sen( nvolce To:
C:mol Police Drip@rimont
Attn: P:2 Young
3 CIvic Squ@m
Carol, IN 6I - PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT I PROJECT ACCOUNT AMOUNT
CSI mel Police DW. PAYMENT $1,40.00
• A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT T'ERE IS AN UNOBLIGATED BALANCE IN
THIS APPROPRIAT UPFICIENT TO PAY FOR THE ABOVE ORDER.
•SHIP REPAID.
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED.
•PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY
SHIPPING LABELS. jhld Q/�I Police®II�O
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
CLERK-TREASURER
DOCUMENT CONTROL NO. 3 2 2 3 0' A.P.V. COPY-SIGN AND RETURN TO CLERK'S OFFICE
VOUCHER NO.-_--- WARRANT NO.
ALLOWED 20
IN THE SUM OF$
ON ACCOUNT OF APPROPRIATION FOR
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 the
materials or services itemized thereon for
which charge is made were ordered and
received
20
Signature
------ ------- ----------- --- Title
Cost distribution ledger-classification if
claim paid motor vehicle highway fund
Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
ACCOUNTS PAYABLE VOUCHER
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))
01/02/15 i-1995725-PRE-CF applicant testing $1,400.00
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
Professional Psychological Services
IN SUM OF $
10293 North Meridian St, Suite 375
Indianapolis, IN 46290
2-, 1 ��
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Encumbered I hereby certify that the attached invoice(s), or
32238 1-1995725-PRE-Ci 43-419.99 I $1,400.00
bill(s) is (are)true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
-I L�DvLk � -ct G1 ��v received except
Wednesday, ecember 31, 2014
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund