HomeMy WebLinkAbout242515 02/24/15 CITY OF CARMEL, INDIANA VENDOR: 079900
d i ONE CIVIC SQUARE GARY DUFEK CHECK AMOUNT: $*******400.00*
s ;r° CARMEL, INDIANA 46032 12610 OVERTURE DRIVE CHECK NUMBER: 242515
CARMEL IN 46033 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.
Plan Participant/Payee:
Gary Dufek
12610 Overture Drive
Carmel, IN 46033
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: February 23, 2015
I i
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
Gary Dufek Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
contribution $400.00
02123115 2.23.15
Total
I 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 N921:24115 WARRANT NO.
ALLOWED 20
IN SUM OF $
12610 Overture Drive
Carmel. In 46033
$$400.00
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 ao0.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
// .. 20
C�-
`� Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund