247199 07/15/15 yo'.�,A+, CITY OF CARMEL, INDIANA VENDOR: 368374
ONE CIVIC SQUARE RITA COLLINS CHECK AMOUNT: $*******300.00*
a CARMEL, INDIANA 46032 4389 ELKHORN DRIVE CHECK NUMBER: 247199
9.;��___;r: WESTFIELD IN 46062
„oN�• CHECK DATE: 07!15/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 145800 300.00 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 Icheck to Human Resources for further processing.
Plan Participant/Payee:
Rita Collins
4389 Elkhorn Drive
Westfield,IN 46062
Amount: $300.00
Fund: Medical Escrow Fund (301)
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Date: July 6,2U15
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Submitted To
JUL 13 2015
Clerk Treasurer
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Forth No.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
Rita Collins
Purchase Order No.
Terms
Date Due
Invoice InvoiceDescription Amount
Date Number (or note attached invoice(s) or bill(s))
07108115 07.06.15 h Savings Ar-r-olint Incentive
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Total $300.00
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.
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20
Clerk-Treasurer
VOUCHER NGb7 jm5 WARRANT NO.
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ALLOWED 20
Riga Collins IN SUM OF $
4389 Elkhorn Drive
Westfield, IN 46062
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$300.00
ON ACCOUNT OF APPROPRIATION FOR
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301 Medical Fund
Board Members
PO#or
DEPT.# INVOICE NO. ACCT#/TITLE AMOUNT i, I hereby certify that the attached invoice(s),
or bill(s) is (are) true and correct and that
07.06.15 301 $300.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
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Signature
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund