252158 12/02/15 �,A,f. CITY OF CARMEL, INDIANA VENDOR: 366267
;; 3. ONE CIVIC SQUARE ASHLEY ULBRICHT CHECK AMOUNT: $""''"'*413.64'
., ;� CARMEL, INDIANA 46032 433 AUTUMN DRIVE CHECK NUMBER: 252158
'M,i tory ca. CARMEL IN 46032 CHECK DATE: 12/02/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1180 4343004 413.64 TRAVEL PER DIEMS
'escribed by State Board of Accounts General Form No.101(1955)
MILEAGE CLAIM
City of Carmel, Indiana TO ��Y11,C M U r G - DR.
(Governmental Unit) j
Department of Law - 1180 On Account of Appropriation No. 434-3004 for Mileage
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE @ 675
20Point Point Start Finish TRAVELED PER MILE
i (p 1 tami► C o uv a t v
ZJ
1
S
os
S � �
S
7 '
'71
1
Cl' a ¢
c
7 3 C a) C +- . 0-1,1Jv oy0h 4µ � .e 313 4
a<< 617
g 13 cay VV%iLl \ ( t t i 7
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.
ursuant to the provisions and penalties of Chapter 155, Acts 1953, i hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
lowing all just credits, and that no part of the same has.been paid.
ate
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
` That it is duly authenticated as required
by law;
That it is based upon statutory authority;
ct
$ L J/.2 ;J That it is apparently incorrect
On Account of Appropriation No.4343004 for
Disbursing Officer
Department of Law - 1180
Q C2
Allowed 20 a p
in the suof$ o
m @ n
¢�
(D r
� m �
(D
(D
rt
(Board or commission) 0
rt (D D (D
'-t
(
(D p
FILED rn d•4-
M
0 N
(D
A
m
0 (D
r+
----
(Official Title) (D
yyy(p
h O �
(D �Cj
O