247214 07/1 5/1 5 Coq -
1y
CITY OF CARMEL, INDIANA VENDOR: 369140
e 5; ONE CIVIC SQUARE JANICE DAVIS CHECK AMOUNT: $***"*""300.00*
CARMEL, INDIANA 46032 14846 VICTORY COURT CHECK NUMBER: 247214
I CARMEL IN 46032 CHECK DATE: 07/15/15
t ETON�
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 300.00 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:
Janice Davis
14846 Victory Court
Carmel, IN 46032
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: July 6, 2015
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Farm 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
Janice Davis
Purchase Order No.
Terms
Date Due
Invoice lnvoice Description Amount
Date Number, (or note attached invoice(s) or bill(s))
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Total $300.00
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 X1.6.
, 20-
Clerk-Treasurer
20Clerk-Treasurer
VOUCHER NOQU13i15 WARRANT NO.
ALLOWED 20
�BnI �16VIS IN SUM OF $
14846 Victory Court
Carmel, IN 46032
$ $300.00
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ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
Board Members
PO#or DEPT.# INVOICE NO. ACCT#/TITLE AMOUNT I hereby certify that the attached invoice(s),
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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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20
i Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund