HomeMy WebLinkAbout247226 07/15/15 Q
CITY OF CARMEL, INDIANA VENDOR: 00351588
ONE CIVIC SQUAOE RICHARD DUFEK CHECK AMOUNT: $*i******400.00•
CARMEL, INDIANI 46032 850 HADLEIGH PASS CHECK NUMBER: 247226
WESTFIELD IN 46074 CHECK DATE: 07/15/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400.00 OTHER EXPENSESI
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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:
Richard Dufek
850 Hadleigh Pass
Westfield, IlY 46074
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: July 6 2015
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Prescribed by State Board ofAccounts l ACCOUNTS PAYABLE VOUCHER City Form 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, n lumber of hours, rate per hour, number of units, price per unit, etc.
Payee
Richard Dufek
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
07106115 Q7 ng 15 Savings Account Ineentive
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Total $400.00
I hereby certify that the attached invoice(s), or bill(s), is (are)true and correct and I have audited same in accor-
dance with IC 5-11-10- 6.
, 20-
Clerk-Treasurer
20Clerk-Treasurer
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VOUCHER NQjyj&15 WARRANT NO.
ALLOWED 20
arfl!
--��# rJ rl�i�f e IN SUM OF$
850 Hadleigh Pass
Westfield, IN 46074
$$400.00
ON ACCOUNT OF APPROPRIATION FOR
l
301 Medical Fund
Board Members
PO# 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 j the materials or services itemized thereon
for which charge is made were ordered and
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received except
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20
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Signature
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund