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308008 02/13/17 w.4�� ''� CITY OF CARMEL, INDIANA VENDOR: 371505 ONE CIVIC SQUARE SAM SHAW CHECK AMOUNT: $t*.... ****x40.00" '. CARMEL, INDIANA 46032 625 MARANA DRIVE CHECK NUMBER: 308008 '4,��oN-�. CARMEL IN 46032 CHECK DATE: 02/13/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1092 4358400 2000504004 40.00 REFUNDS AWARDS & INDE $ kk0 O § - R f / \ 0 k ) / © n @ @ f % c SUE OzCD k 7 # — Cl) / C) 0� 2 \ E / \ \ 2 9 7 \ S n n a ® m (a ƒ 2 $ q / [ S ® \ e o � 2 E w > 2 P & o \ 40 CD k w ] E - D 0 7 0 - = CD ¢ 7 ƒ ƒ E 0 M ] A X m 0 g o CE fA / -0 f ( - k / 2 0 CD Zr (ne E \ k 7 / c8, m ) k I § 0 k 2 2 M 0 0 0 7 ƒ \ k n w CD m J - C k CL % » j § C) / Cr � ƒ / M CD CD f | 0 0 Receint #2000504.004 Page 1 of 1 Monon Community Center West Voucher #2000504.004 Building Feb 5, 2017 3:10 PM 1195 Central Park Dr. West Carmel, IN 46032 Phone: (317) 848-7275 FAX: -- Car el * Clay Email: info@carmelclayparks.com yp Parks&Recreation NATIONAL GOLD MEDAL WINNER SAM SHAW 625 MARANA DR AND ACCREDITED AGENCY CARMEL, IN 46032 Prepared By: hollypg Customer ID: 58655 Primary phone: (317) 414-7210, Secondary phone: (317) 414-7210 Refund Summary Check: ($40.00) Check # Total Received: ($40.00) Total Refund: ($40.00) Transactions Customer Description Item Unit Qty Fee Charge Sam Shaw Escape Pass-Adult Monthly Membership Each 1.00 $40.00 ($40.00) 625 MARANA DR Action: Membership Cancel Fee CARMEL,IN 46032 Expires: Jan 30, 2017 Primary phone:(317)414- Pass# 130051467: Sam Shaw 7210 Thanks for your purchase!This pass will Email: automatically renew each month, until cancellation miioandbono@yahoo.com request is received. Cancellation request must be ID: 58655 received 7 days prior to billing date. Total Charges ($40.00) Total Payments ($40.00) Balance $0 Federal Tax ID # 35-6000972 � t voitAwl BY: 6 https:Hanprod.active.com/carmelclayparks/servlet/processReceiptPayment.sdi 2/5/2017