247751 07/28/15 �4q -
CITY OF CARMEL, INDIANA VENDOR: 369661
b i{ ONE CIVIC SQUARE JENNIFER BEERY CHECK AMOUNT: $**.....390.86*
s ?4 CARMEL, INDIANA 46032 14109 WELFORD WAY CHECK NUMBER: 247751
9,,�,TQN � CARMEL IN 46032 CHECK DATE: 07/28/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 396000 REFUND 390.86 REFUNDS
Ci EL
J:VNIES BRAINARD, NL,,1'OR
July 24, 2015
Jennifer Beery
14109 Welford Way
Carmel, IN 46032
RE: RUN # 20144335:1 DOS 09/03/2014
Dear Jennifer Beery:
Enclosed you will find a refund check for $ 390.86.
We received a credit card payment of$ 390.86 on 12/05/2014 from Bradley Beery.
On 05/22/2015 Advantage Health processed your claim and paid $ 390.86 and we are
sending you the overpayment
If you have any questions, please feel free to contact me at (3 17) 571-2604.
Sincerely,
I �
Michelle T. Harrington
EMS Billing Administrator
CARMEL TIRE DERARTNIENT
S"I'I?VEN A. COUPS HEADQUARTERS
Two CIVIC SQUARE, CAILi9EL, IN 46032 OFFICE 317.571.2600, F,,, 317.571.2615
y CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL, IN 46032-2584
CL"11%7. (317) 571 2604 Federal ID# 356000972
Patient Name: BEERY, JENNIFER
JENNIFER BEERY CARMEL FIRE DEPARTMENT
14109 WELFORD WAY 2 CIVIC SQUARE
CARMEL, IN 46032 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/24/15 990108017
Ticket# : 20144335:1
Date of Service: 9/3/2014
DETACH HERE
REFUND $390.86 BRADLEY BEERY WE RECEIVED HIS PAYMENT AND DUPLICATE PAYMENT II
FROM ADVANTAGE HEALTH.
f'
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20144335:1
Online Payment will charge a service fee.
Date Of.Senrice = : Description',.., - Patierit'Name Gfiaige(s)"` Date :'Payment(s)' ','
Charges
9/3/2014 "BASIC LIFE SUP BEERY, JENNIFER $375.00
9/3/2014 "MILEAGE BEERY, JENNIFER $15.86
---------------------------------
Charge Total: $390.86
Payments
Paid By: Invoice 09/03/14 $390.86
Paid By: BEERY, JENNIFER Payment 12/05/14 ($390.86)
Paid By: ADVANTAGE 360 SAGAMORE COMMERCIAL INSURANCE 05/22/15 ($390.86)
Paid By: BEERY, JENNIFER REFUND 07/24/15 $390.86
BALANCE $0.00
Prescribed by State Board of Accounts 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, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5-11-10-1.6.
20
Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
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 the
materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund