247390 07/1 5/1 5 ^'�.�,q,� CITY OF CARMEL, INDIANA VENDOR: 00353199
��,: CHECK AMOUNT: $""'"""400.00"
ONE CIVIC SQUARE ERNIE MAROON
,� CARMEL, INDIANA 46032 1004 RETFORD DR CHECK NUMBER: 247390
y TON�, WESTFIELD IN 46074 CHECK DATE: 07/15/15
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:
Ernest Maroon
1004 Retford Drive
Westfield, IN 46074
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: July 6, 2015
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
Ernest Maroon
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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 5-11-10-1.6.
, 20
Clerk-Treasurer
VOUCHER N%4345—WARRANT NO.
ALLOWED 20
Ernest M reen I IN SUM OF $
1004 Retford Drive
VVestfield, IN 46074
$x$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
20
Signature
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund