242591 02/24/15 >`. CITY OF CARMEL, INDIANA VENDOR: 00353016
(� ONE CIVIC SQUARE BOB PELZER CHECK AMOUNT: $*******300.00*
4 ?
CARMEL, INDIANA 46032 14350 WEEPING WILLOW COURT CHECK NUMBER: 242591
?y�ror Ea. CARMEL IN 46033 CHECK DATE: 02/24/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 300.00 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:
Robert Pelzer
14350 Weeping Willow Court
Carmel, IN 46033
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: February 23, 2015
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHERCity 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
Robert Pelzer Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
tion $300.00
02123115 92.23.15 _
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 N012/24/15 WARRANT NO.
ALLOWED 20
Rohert Pelzer IN SUM OF $
14350 Weeping Willow Court
Carmel; In 46033
$$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 1,300.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
20
�« ignature 1 Z_
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund