242602 02/24/15 0�`r�'� "p;% CITY OF CARMEL, INDIANA VENDOR: 00350010
d t ONE CIVIC SQUARE TERESA RICKARD CHECK AMOUNT: S""""300.00'
CARMEL, INDIANA 46032 539 MALLORY HILL DRIVE CHECK NUMBER: 242602
'"; ,�� THE VILLAGES FL 32162 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:
Teressa Rickard
539 Mallory Hill Drive
The Villages, FL 32162
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: February 23, 2015
I
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
Teressa Rickard
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0 300.00
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 Noga4 _WARRANT NO.
ALLOWED 20
Teressa Rickard IN SUM OF $
539 Mallory Hill Drive
The-V illa ws.,_F l 32162
93on nn
ON ACCOUNT OF APPROPRIATION FOR
*Inn 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
0223,15 301 300.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
20
Signature f
L v H-f?
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund