251178 11/04/15 r_Coq
CITY OF CARMEL, INDIANA VENDOR: 369991
ONE CIVIC SQUARE CHRISTOPHER MARONEY CHECK AMOUNT: S"'""'511.24'
?4 CARMEL, INDIANA 46032 12818 ANDOVER DRIVE CHECK NUMBER: 251 178
MiTON,`°� CARMEL IN 46033 CHECK DATE: 11/04/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 511.24 OTHER EXPENSES
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CITY 4 OF RMEL
JAvmF-S BRAINARD, TVI�Y'OR
November 2, 2015
CHRISTOPHER MARONEY
12818 ANDOVER DR
CARMEL, IN 46033
RE: RUN 4 20153384:1 DOS 07/08/2015
Dear Christopher Maroney:
Enclosed you will find a refund check for $511.24
We received your check 41446 for$511.24 for this invoice.
On 10/29/2015 First Farmers Bank & Trust processed your claim and paid $511.24.
Duplicate payments created overpayment on this account.
Refitnd is owed to Christopher Maroney.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CAILMEL FIRE DEPARTMENT
STEVEN A. COUTs HEADQUARTERS
T\ro CnrIC SOUARE. CAIUAEL. IN 46032 OFFICE 317.571.2600. FAx 317.571.2615
CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL, IN 46032-2584
(317) 571 2604 Federal ID# 356000972
Patient Name: MARONEY, ABAGAIL
ABAGAIL MARONEY CARMEL FIRE DEPARTMENT
C/O CHRISTOPHER MARONEY 2 CIVIC SQUARE
12818 ANDOVER DR CARMEL, IN 46032-2584
CARMEL, IN 46033
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 11/02/15 201202100 `
Ticket# : 20153384:1
Date of Service: 7/8/2015
DETACH HERE
REFUNDING YOUR PAYMENT 10/07/2015 CK#1446 $511.24. FIRST FARMERS BANK&TRUST
ALSO MADE A PAYMENT ON 10/29/2015 CK#2028345 FOR$511.24. ACCOUNT PAID IN FULL.
THANK YOU
P;
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0.00:
Pay online at www.govpaynet.com with PLC#7487 Run Number 20153384:1
Online Payment will charge a service fee.
Date=of Service" Description:• = - ':' Patient-Name,: _ =CFarge_(s)•' :Date:.-'::
_P
Charges
7/8/2015 *ADVANCED LIFE MARONEY, ABAGAIL $475.00
7/8/2015 *MILEAGE MARONEY, ABAGAIL $36.24
---------------------------------
Charge Total: $511.24
Payments
Paid By: Invoice 07/08/15 $511.24
Paid By: MARONEY, ABAGAIL Payment � / 10/07/15 ($511.24)
Paid By: SAGAMORE HEALTH NETWORK COMMERCIAL INSURANCE 10/29/15 ($511.24)
- z k 20)-S3gS
Paid By: MARONEY, ABAGAIL REFUND 11/02/15 $511.24
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.
120-
Clerk-Treasurer
20Clerk-Treasurer
h
1
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
3 701%
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund