HomeMy WebLinkAbout259823 06/16/16 4y/1 F/qy�
CITY OF CARMEL, INDIANA VENDOR: 370302
® ONE CIVIC SQUARE VISION SERVICE PLAN CHECK AMOUNT: $""'""9,936.49'
9 ,� CARMEL, INDIANA 46032 PO Box 742788 CHECK NUMBER: 259823
�'��Pm(E°, LOS ANGELES CA 90074-2788 CHECK DATE: 06/16/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 060116 9,936.49 OTHER EXPENSES
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995)
VISION SERVICE PLAN ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
PO BOX 742788 IN SUM OF$ CITY OF CARMEL
An invoice or bill to be properly itemized must show:kind of service,where performed,dates service
LOS ANGELES, CA 90074-2788 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
$9,636.49 Payee
ON ACCOUNT OF APPROPRIATION FOR Purchase Order#
301 Medical Fund Terms
Date Due
PO# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
06.01.16 50-239.90 $9,636.49 1 hereby certify that the attached invoice(s),or 6/13/16 06.01.16 $9,636.49
301 301 301 301
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
Tuesday,June 14,2016
Aa"�
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
Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
Page 1 _ b
• 1
Account Number: 12 013661 0001 VS
Bill Print Date: JUNE 01, 2016 For JUNE 2016
Membership Received After: The 15th of the month will reflect on your next bill.
Payment Due Date: Upon receipt of this bill
CITY OF CARMEL C/O
BARBARA LAMB
1 CIVIC SQUARE
CARMEL IN 46032-2584
Prior Billing Period Activity
Amount Previously Billed $9,653.76
Payments/Billing Adjustments -$9,653.76
Outstanding Receivable Total _ _ _ —$0.00 --
Current Billing Period Activity
Current Charges $9,636.49
Please Pay This Amount $9,636.49
1 -31 Days 32 61 Days 62-91 Days >92°Days
$9,636.49 ;$0.00 $0.00 $0.00
EJUN)'n tt' T O 13 2016
T reesurer
Questions? Please call 1-866-213-2249 if you have questions regarding your bill or membership.
Passion for people. Vision for life. sm
Please detach and return this portion with your payment --------
Bill Print Date: JUNE 01, 2016 for JUNE 2016
Group Name: CITY OF CARMEL Attn: Revenue Administration R00251
Account Number(s): 12 013661 0001
0001
Amount Due $9,636.49
Return To:
VISION SERVICE PLAN
Amount Paid $
P.O. BOX 742788 Number Paid For
LOS ANGELES, CA 90074-2788
❑ Please check here if you are not paying the entire amount due and indicate any adjustments on the back
side of this payment coupon
SUMM-R00251 -D-M---- - - -00-229--
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