249649 09/23/15 Jif"C�N11.
CITY OF CARMEL, INDIANA VENDOR: 065950
b t, ONE CIVIC SQUARE DIANA CORDRAY CHECK AMOUNT: $'..."'*`44.85'
:• ,,r° CARMEL, INDIANA 46032 11843 STONEY BAY CIRCLE CHECK NUMBER: 249649
CARMEL IN 46033-9501 CHECK DATE: 09/23/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1701 4343004 44.85 TRAVEL PER DIEMS
Prescribed by State Board of Accounts General Form No.101 (1955)
MILEAGE CLAIM
TO DR.
(Governmental Unit)
On Account of Appropriation No. ��' 'Ul for
(Office, Board, epartment r stitution)
93
DATEE FROM TO ODOMETER READING' NATURE OF BUSINESS AUTO MILES MILEAGE @�
2015 Point Point Start Finish TRAVELED PER MILE
V/Lkf'1 s 0
eZ91—
YH -�I- Dvl ' s
u Y
I
Auto License No. TOTALS
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
allowing all just c its, and that
no part
o�f the same has been paid.
Date ( O�
Claim No. warrant No. I have examined the within claim and
hereby certify as follows:
INF VOR OF
�� � That it is in proper form;
—1+4AThat it is duly authenticated as required
by law;
That it is based upon statutory authority;
�J �� That it is apparently correct
$ ` r-1 incorrect
On Account of Appropriation No. � for
Disbursing Officer
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