242516 02/24/15 CITY OF CARMEL, INDIANA VENDOR: 00351588
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ONE CIVIC SQUARE RICHARD DUFEK CHECK AMOUNT: $*******400.00*7 CARMEL, INDIANA 46032 850 HADLEIGH PASS CHECK NUMBER: 242516
WESTFIELD IN 46074 CHECK DATE: 02/24/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400.00 HSA
i
City of Cannel 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.
I Please return check to Human Resources for further processing_
Plan Participant/Payee:
Richard Dufek
850 Hadleigh Pass
Westfield, IN 46074
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: February 23, 2015
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City FormNo.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
Richard Dufek
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0:212311 0:2 23 1 R 1 Health Savings Account Contribution $400.00
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
VOUCHER N002/24/15 WARRANT NO.
ALLOWED 20
Richard Dufek IN SUM OF $
850 Hadleigh Pass
Westfield, IN 46074
$ $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 S400.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
20
Signature
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Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund