241068 1 /13/2015 (9,
CITY OF CARMEL, INDIANA VENDOR: T357649
ONE CIVIC SQUARE LETICIA KRUZIL CHECKAMOUNT: $********40.26*
CARMEL, INDIANA 46032 831 NANSEMOND CHECK NUMBER: 241068
CARMEL IN 46032 CHECK DATE: 01/13/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1092 4358400 40.26 REFUNDS AWARDS & INDE
GLOBAL REFUND RECEIPT
Receipt# 1386466 :,. 1 I�p
Payment Date: 01/05/2015
Household#: 869 & f' 3�tf1:
Home Phone: (317)848-29727NJA
TVED
D6. 2015
LETICIA M. KRUZIL BY: Monon Community Center
831 NANSEMOND Carmel IN 46032
CARMEL IN 46032
Phone: (317)848-7275
Fed Tax ID#35-6000972
---Pass Details - — —
CANCELLATION -Refund Of 40.26
Pass Holder: Leticia M. Kruzil Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: UnGrpFit Annual (M UGFA),#20343 259.74 0.00 259.74 0.00 0.00
Valid Dates: 02/23/2014 to 02/23/2015 (Pass Cancellation)
Cancellation Effective: 01/05/2015
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
nFitness Prog Passes 259.74 1.00 0.00 0.00 259.74
Cancel Reason: Guest Request-Silver Sneakers
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 01/05/15 @ 10:50:57 by MNS FEES CHANGED ON CANCELLED ITEMS(+) 40.26-
DISCOUNT APPLIED AGAINST CANCELLED FEES(-) 0.00
SALES TAX CHARGED ON CANCELLED FEES(+) 0.00
NET AMOUNT FROM CANCELLED ITEMS40.26-
[-TOTAL AMOUNT.REFUNDED 40.26.
NEW NET HOUSEHOLD BALANCE 0.00
Refund of=_> 40.26 Made By==>REFUND FINAN With Reference==>Guest Request;Silver Sneakers
All refunds are subject to State Board of Accounts procedures and may take 4-6 weeks to process. No cash refunds will be
issued. —
.�11U t -r�,�n
horized Sign t re Date Authorized Signature D to
Escape Day Passes are non-refundable.
Page# 1 of 1
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
Kruzil, Leticia M. Terms
831 Nansemond Date Due
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
1/5/15 1386466 . Refund $ 40.26
Total $ 40.26
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
i
I
Voucher No. Warrant No.
I
Kruzil, Leticia M. Allowed 20
831 Nansemond
.Carmel, IN 46032
In Sum of$
i
$ 40.26
I
ON ACCOUNT OF APPROPRIATION FOR I
I
109 -MCC
DepDept Board Members
INVOICE NO. ACCT#/TITLE AMOUNT
I
1092 1386466 4358400 $ 40.26 1 hereby certify that the attached invoice(s), or
bill(s) is (are)true and correct and that the
materials or services itemized thereon for
I
which charge is made were ordered and
rEceived except
I
January 8, 2015
i
Signature
$ 40.26 i Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund