HomeMy WebLinkAbout300823 07/21/16 `'���,q�° CITY OF CARMEL, INDIANA VENDOR: 370870
`= `' CHECK AMOUNT: $******`181.80*
.,_ ® `I• ONE CIVIC SQUARE PAUL DAVIS
9� =a CARMEL, INDIANA 46032 11986 TAVERNIER DR CHECK NUMBER: 300823
,,,_TON�, FISHERS IN 46037 CHECK DATE: 07/21/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 071316 181.80 OTHER EXPENSES
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
(6 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
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
r_
- ae
I, ISI
'I' A /IEL
CI
JAMEs BRAINARD, MAYOR
July 13, 2016
Paul Davis
11986 Tavernier Dr.
- Fishers, IN 46037
RE: RUN #20160363:1 DOS 01/21/2016 Nathan Davis
Dear Paul Davis:
Enclosed you will find a refund check for$181.80.
Discovery.Benefits your health spending account sent a check for $181.80.
This account was closed paid in full on 04/20/2016 check# 007220.
Duplicate payment received created overpayment.
Refund to be issued to Paul Davis.
If you have any questions, please feel free to contact me at(317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. COUTs HEADQUARTERS
Twn Crvrr gnTTARR (-.ARYTT7T TN A(02,? (lccrrc 217 C71 ')(,nn V— 217 c-71 ')r-1C
CARMEL FIRE DEPARTMENT
ir 10` 2 CIVIC SQUARE
CARMEL, IN 46032-2584
'• (317) 571 2604 Federal ID#356000972
Patient Name: DAVIS, NATHAN
NATHAN DAVIS CARMEL FIRE DEPARTMENT
C/O JILL DAVIS 2 CIVIC SQUARE
11986 TAVERNIER DR CARMEL, IN 46032-2584
FISHERS, IN 46037
TO ASSURE PROPER CREDIT, RETURNStatement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/13/16 990112857
Ticket# : 20160363:1
Date of Service: 1/21/2016
DETACH HERE
DISCOVERY BENEFITS SENT PAYMENT FOR$181.80.ACCOUNT ALREADY PAID IN FULL.
OVERPAYMENT REFUND PAUL DAVIS $181.80. THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0 00
Pay online at www.govpaynet.com with PLC#7487 Run Number 20160363:1
Online Payment will charge a service fee.
3 fi n z r r 5, } Parnent s `
Date of rService, Descr�ptionr 4- =P,atient Names � � �Charge(s) Date ' y O '
+..i( .» ..>..--x
Charges
1/21/2016 *BASIC LIFE SUP DAVIS, NATHAN $675.00
1/21/2016 "MILEAGE DAVIS, NATHAN $234.00
---------------------------------
Charge Total: $909.00
Payments
Paid By: Invoice 01/21/16 $909.00
Paid By: PROHEALTH GOLD PLAN COMMERCIAL INSURANCE 02/25/16 ($727.20)
Paid By: DAVIS, NATHAN Payment I'"c1,U{,l J)a.Ul`5 (X 2V4/20/16 ($181.80)
Paid By: DAVIS, NATHAN COMMERCIAL INSURANCE 07/13/16 ($181.80)
Ors-DW-rpoellef► f- C c OO23qSf2o
Paid By: DAVIS, NATHAN REFUND 07/13/16 $181.80
BALANCE $0.00