242816 03/03/15 CITY OF CARMEL, INDIANA VENDOR: 369146
ONE CIVIC SQUARE MONIKA PLATA CHECK AMOUNT: $*******475.00*
CARMEL, INDIANA 46032 13135 PLAYER CIRCLE CHECK NUMBER: 242816
CARMEL IN 46032 CHECK DATE: 03/03/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 475.00 OTHER EXPENSES
PV
CITY'~=I' C EL
JAMES BRAINARD, MAYOR
March 2, 2015
Monika Plata
13135 Player Circle
Carmel, IN 46033
RE: INVOICE#20143713:1 DOS 07/27/2014
Dear Monika Plata:
Enclosed you will find a refund check for$ 475.00.
We received your payment of$ 562.58 on 12/05/2014 and Pro Health processed your
your claim and paid$ 475.00 and we are sending you the overpayment.
If you have any questions,please feel free to contact me at(317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. COUTS HEADQUARTERS
Two Cmc SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL, IN 46032-2584
(317) 5712604 Federal ID#356000972
Patient Name: PLATA, MONIKA B
MONIKA PLATA CARMEL FIRE DEPARTMENT
13135 PLAYER CIRCLE 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 03/02/15 990107683
_ Ticket#:-20143713:1 _
Date of Service: 7/27/2014
DETACH HERE
REFUND MONIKA PLATA $475.00 SHE PAID THIS INVOICE ON 12/05/2014 AND ON 02/03/2015
5
PRO HEALTH PAID CLAIM. OVERPAYMENT
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE - $0;00,"
Pay online at www.govpaynet.com with PLC#7487 Run Number 20143713:1
Online Payment will charge a service fee.
� 4f5 ;y .t-.. 4 "Y4
Date`of Service Description � P5tidnt.Name Charges) Date Payments) -,
a st ,Y•f}4"r'vMry x+�+#'. !4 e'Y K-$i..r '�; d tw., i'..�;; �'�:. '� :-.. L`i .crrh, '�''� —
Charges
7/27/2014 *ADVANCED LIFE PLATA, MONIKA B $475.00
7/27/2014 *MILEAGE PLATA, MONIKA B $87.58
---------------------------------
Charge Total: $562.58
Payments
Paid By: Invoice 07/27/14 $562.58
Paid By: PLATA, MONIKA B Payment 12/05/14 ($562.58)
Paid By. PRO HEALTH/HEALTHREWARD COMMERCIAL INSURANCE 02/03/15 ($475.00)
Paid By. PLATA, MONIKA B REFUND 03/02/15 $475.00
BALANCE $0.00
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
Purchase Order No:
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5-11-10-1.6.
, 20-
Clerk-Treasurer
20Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF $
I
i
ON ACCOUNT OF APPROPRIATION FOR
i
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 the
materials or services itemized thereon for
which charge is made were ordered and
received except
i
MAR 2
i
015
e
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund