247174 07/1 5/1 5 Yf�- CITY OF CARMEL, INDIANA VENDOR: 00351349
i;® l ONE CIVIC SQUARE DOUGLAS CALLAHAN CHECK AMOUNT: $*******400.00*
_� CARMEL, INDIANA 46032 1015 EAST 106TH STREET CHECK NUMBER: 247174
9.,;�..__ INDIANAPOLIS IN 46280 CHECK DATE: 07/15/15
ICON GO
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400.00 OTHER EXPENSES
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:
Douglas Callahan
1015 East 106th Street
Indianapolis,IN 46280
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: July 6, 2015
Prescribed by State Board of Accounts City Forth Na.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
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
Douglas Callahan
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
OV06/15 Savings Armwunt Incentive 400.00
Total
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 N(�yg3/1� WARRANT NO.
ALLOWED 20
IN SUM OF $
1015 East 106th Street
Indianapolis, IN 46280
a
1
$$400.00
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
( Board Members
Po#or IN NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s),
or bill(s) is (are) true and correct and that
07.06.15 301 $400.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
i
I
20
Signature
Cost distribution ledger classification if
' Title '
claim paid motor vehicle highway fund