HomeMy WebLinkAbout242603 02/24/15 "'• CITY OF CARMEL, INDIANA VENDOR: 00350917
ONE CIVIC SQUARE KIM ROTT CHECK AMOUNT: $*******400.00*
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CARMEL, INDIANA 46032 1303 HOLLYCREST DRIVE CHECK NUMBER: 242603 BLOOMINGTON IL 61701 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:
Kimberly Rott
1303 Hollycrest Drive
Bloomington, IL 61701
Amount: $400.00
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
Kimberly Rott Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
02/23/1 b 02.23.15 Annual Flealth ngs Aceount Contribution $40000
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 N5—WARRANT NO.
ALLOWED 20
Klmberiy Rett IN SUM OF $
1303 Hollycrest Drive
Bloomington, IL 61701
$$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 x00.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
rl 20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund