246260 06/17/15 CITY OF CARMEL, INDIANA VENDOR: 065950
,`® j• ONE CIVIC SQUARE DIANA CORDRAY CHECK AMOUNT: $**"'"'123.25*
s9 a CARMEL, INDIANA 46032 11843 CARMEL MN46033-9501
IRCLE CHECK NUMBER: 246260
CHECK DATE: 06/17/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 123.25 STATE SCHOOL
Prescribed by State Board of Accounts General Form No.101 (1955)
MILEAGE CLAIM
�/14 el TO l/ C�7� �/�'i/ �w ��(^ DR.
(Governmental Unit)
V On Account of Appropriation No. I for
Office,Board,Department or Institution
DA/TETE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE @ �
201- Point Point Start Finish TRAVELED PER MILE
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/N
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Auto License No. TOTALS
*SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map. CX d
Pursuant to the provisions and enalties of Chapter 155 Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after I csL�
p p P � Y fY 9 9 J 9 Y
allowing all just credits, and that no part of the same has been paid.
Date
I
I
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
CN►'
That it is duly authenticated as required
by law;
That if is based upon statthority;
That it is apparently ect
jfr�r
eat
i On Account of Appro nation No. O 1 for
Disbursing Officer
Allowed 20 o �
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