241595 01/27/15 4y'e�4gMf CITY OF CARMEL, INDIANA VENDOR: 369065
.r; ® ,• ONE CIVIC SQUARE MARY SIMONS
CHECKAMOUNT: $"""•110.00'
�. ?a CARMEL, INDIANA 46032 13446 CLIFTY FALLS DRIVE CHECK NUMBER: 241595
9,,�,___�i, CARMEL IN 46032 CHECK DATE: 01/27/15
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1096 4358400 110.00 PARKS DEPARTMENT REFU
ACTIVITY REFUND RECEIPT
Receipt# 1396162
'arml isClay Payment Date: 01/19/15
Parks&Recreation Household#: 54929
lC l c�� `'� a
Monon Community Center Mary Simons Hm Ph: (317)429-6932
Carmel IN 460327B)Y(:
'�"� 13446 Clifty Falls Dr
Carmel IN 46032 Cell Ph:
Phone: (317)848-7275
2 2015 mrndaisy@yahoo.com
Fed Tax ID#35-6000972 -----
Enrollment Details
CANCELLATION Refund Of 110.00
Enrollee Name: Arl Simons Fees+Tax Discount Prev Paid Cur Paid Amount Due
Activity Number: 355102-01 Wee Move&Groove 0.00 0.00 0.00 0.00 0.00
Enrollment Date: 01/11/2015 (Cancelled)
Class Location: Dance Studio B Class Dates: 01/20/2015 to 04/21/2015
Monon Community Cntr 10:30A to 11:OOA
Tu
Carmel, IN 46032 Scheduled Sessions: 13
(317)848-7275
Skip Days 04/07/2015
Cancel Reason: Low Enrollment
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 01/19/15 @ 10:52:00 by AJACKSON FEES CHANGED ON CANCELLED ITEMS(+) 110.00-
NET AMOUNT FROM CANCELLED ITEMS 110.00-
TOTAL AMOUNT REFUNDED 110.00
NEW NET HOUSEHOLD BALANCE 0.00
Refund of==> 110.00 Made By=- REFUND FINA With Reference==>
All refunds are subject to State Board of Accounts procedures and may take 4-6 weeks to process. No cash refunds will be
issued.
e
Authorized Signature date, Authorized Signature Date
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.
Simons, Mary Terms
13446 Clifty Falls Drive Date Due
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
1/19/15 1396162 Refund $ 110.00
Total $ 110.00
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
120
Clerk-Treasurer
Voucher No. Warrant No.
Simons, Mary Allowed 20
13446 Clifty Falls Drive
Carmel, IN 46032
In!Sum of$
i
$ 110.00
II�
ON ACCOUNT OF APPROPRIATION FOR 1
109 -MCC
PO#or Board Members
INVOICE NO. ACCT#/TITLE AMOUNT
Dept#
1096-32. 1396162 4358400 $ 110.00 1 I�ereby 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
i
January 22, 2015
Signature
$ 110.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
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