242568 02/24/15 CITY OF CARMEL, INDIANA VENDOR: 00353199
ONE CIVIC SQUARE ERNIE MAROON CHECK AMOUNT: $*******400.00*
9M( N co CARMEL, INDIANA 46032 1004 REI
ELD a FORD
ora CHECK NUMBER: 242568
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:
Ernest Maroon
1004 Retford Drive
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 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
Ernest Maroon Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
02123115 02.23.15 Annual Health Savings Aceount ContFibutbo-n $400.0
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
VOUCHEMR/_WARRANT NO.
ALLOWED 20
Ernest Maroon IN SUM OF $
J Q04 Retford Drive
Want ield,—IN-46074—
ON
N 46074ON ACCOUNT OF APPROPRIATION FOR
391 Medical Fund
Board Members
I
PO# INVOICE NO. ACCT#/TITLE AMOUNT
DEPT..# I hereby certify that the attached invoice(s),
or bill(s) is (are) true and correct and that
a 0.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
20
` Signature l�2
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund