HomeMy WebLinkAbout242484 02/24/15 Cqq
CITY OF CARMEL, INDIANA VENDOR: 022520
ONE CIVIC SQUARE BRAD BARTROM CHECK AMOUNT: S""'*'300.00`
CARMEL, INDIANA 46032 2802 E 186TH ST CHECK NUMBER: 242484
WESTFIELD IN 46074 CHECK DATE: 02/24/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 300.00 HSA
r
City of Carmel Employee Health Benefit Plan
Health Savings Account Incentive
The retired plan participant listed below has elected Plan A for 2015 and is eligible for a bi-
annual contribution to his or her HSA account, as authorized by Resolution BPW-10-03-12-02.
it Please return check to Human Resources for further processing
Plan Participant/Payee:
Brad Bartrom
P.O. Box 526
Carmel, IN 46082
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: February 23, 2015
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.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
Brad Bartrom Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
02123115 2.23.15
0.00
Total
$300.00---
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 NU2/24/15 WARRANT NO.
ALLOWED 20
Brad BartrOm IN SUM OF $
PO Box 526
Carmel, In 46082
$$300.00
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
02.23.15 301 $300.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
20
Y-, Signature
" -�✓ lct'YL-
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund