308731 02/28/17 0W Coq.
CITY OF CARMEL, INDIANA VENDOR: 00351023
I, ONE CIVIC SQUARE JACE PLATT CHECK AMOUNT: $*******300.00*
,i` CARMEL, INDIANA 46032 4636 ROYAL OAK LANE CHECK NUMBER: 308731
pM�«OX LA` CARMEL IN 46033 CHECK DATE: 02/28/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 02.23.17 300.00 OTHER EXPENSES
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995)
Vendor# 00351023 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
JACE PLATT IN SUM OF$ CITY OF CARMEL
4636 ROYAL OAK LANE An invoice or bill to be properly itemized must show!kind of service,where performed,dates service
rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
CARMEL, IN 46033
Payee
$300.00
Purchase Order#
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund Terms
301 Medical Fund Date Due
PO# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
02.23.17 50-239.90 $300.00 1 hereby certify that the attached invoice(s),or 2/23/17 02.23.17 Bi-Annual Contribution Health Savings Acct $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
Tuesday, February 28,2017
Lamb, Barbara
Director
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
20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
City of Carmel Employee Health Benefit Plan
Health Savings Account Incentive
The retired plan participant listed below 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:
Jace Platt
4636 Royal Oak Lane
Carmel,IN 46033
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: February 23,2017