HomeMy WebLinkAbout300804 07/21/16 y o!_£9ny�
CITY OF CARMEL, INDIANA VENDOR: 022520
`� ® `�\. CHECK AMOUNT: $*******300.00*
ONE CIVIC SQUARE BRAD BARTROM
;S CARMEL, INDIANA 46032 PO BOX 526 CHECK NUMBER: 300804
+;\... �r. CARMEL IN 46082 CHECK DATE: 07/21/16
ETON
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 071816 300.00 OTHER EXPENSES
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995)
BRAD BARTROM ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
2802 E 186TH S t,.r IN SUM OF$ CITY OF CARMEL
An invoice or bill to be properly itemized must show:kind of service,where performed,dates service
W ESTFI ELD, IN 46074 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
$300.00 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
07.18.16 50-239.90 $300.00 1 hereby certify that the attached invoice(s),or 7/18/16 07.18.16 Health Savings Account Incentive $300.00
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
Monday,July 18,2016
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
Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
City of Carmel Employee Health Benefit Plan
Health Savings Account.Incentiv.e. .
The.retired planparficipant listedbelow:has elected-Plan A;for 2016 and is eligible for a bi-
annual contribution to.his.or her HSA account; as authorized by Resolution BPW-10-03-12-02.
Payroll: Please return.check to Human Resources for distribution.
Plan Participant/Payee:
Brad Bartrom
-P.O. Box 526
BE SURE TO USE PO BOX
Carinel;.IN 46082 .
Amount;, $300.00
Fund:: Medical Escrow.Fund:(301).
Date: July:18, 2016