HomeMy WebLinkAbout247225 07/1 5/1 5 q`/ \ CITY OF CARMEL, INDIANA VENDOR: 079900
�5 �l ONE CIVIC! GARY DUFEK CHECK AMOUNT: $*******400.00*
CARMEL, INDIANA 46032 12610 OVERTURE DRIVE CHECK NUMBER: 247225
MUTON�, CARMEL IN 46033 CHECK DATE: 07/15/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400.00 OTHER EXPENSES
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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:
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Gary Dufek
12610 Overture Drive
Carmel, IN 46033
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Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: July 6, 2015
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.199�
CITY OF CARMEL
An invoice or bill to beproperly 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
Gary Dufek
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number, (or note attached invoice(s) or bill(s))
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Total 1 $400.00
I 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.
120
Clerk-Treasurer
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VOUCHER NOa=3Lj5 WARRANT NO.
ALLOWED 20
Gary --449 k IN SUM OF $
12610 Overture Drive
Carmel, IN 46033
$_$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
07.06.15 301 $400.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
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Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund