HomeMy WebLinkAbout242505 02/24/15 CITY OF CARMEL, INDIANA VENDOR: 00351483
it ONE CIVIC SQUARE JOHN CRISLER CHECK AMOUNT: S""'"'400.00'
CARMEL, INDIANA 46032 139 74TH ST CHECK NUMBER: 242505
SOUTH HAVEN MI 49090 CHECK DATE: 02/24/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400.00 HSA
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.
Please return check to Human Resources for further processing_ j
Plan Participant/Payee:
John Crisler
13974 1h Street
South Haven,MI 49090
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: February 23, 3015
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
John Crisler
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
02i23/15 02.23.i 5 Annual Health Savings Account Contribution $400.00I
Total $400.00
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
I
VOUCHER NORa41s WARRANT NO.
ALLOWED 20
Joon Crislpr - IN SUM OF $
139 74th Street
South Haven, MI 49090
X400.00
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 $ 00.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
20
l� Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund