HomeMy WebLinkAbout309624 03/27/17 (9, )
CITY OF CARMEL, INDIANA VENDOR: 371579
ONE CIVIC SQUARE SHANNON PIERCE CHECK AMOUNT: S""""689.40"
CARMEL, INDIANA 46032 15536 SMITHFIELD DR CHECK NUMBER: 309624
WESTFIELD IN 46074 CHECK DATE: 03/27/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 689.40 OTHER EXPENSES
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CITY . . EL
JAMES BRAT A-RD, MAYOR
March 17, 2017
Shannon Pierce
15536 Smithfield Drive
Westfield, IN 46074
RE: RUN # 20161461:1 DOS 03/19/2016 Shannon Pierce
Dear Shannon Pierce:
Enclosed you will find a refund check for$689.40.
We received your payment check #1207 on 09/30/2016 for$689.40
Travelers sent a payment check# 88158133 on 03/17/2016 for$689.40.
Duplicate payments received created overpayment.
Refund to be issued to patient Shannon Pierce.
If you have any questions, please feel free to contact me at(317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
C_11tUIEL Fiul DEPARTMENT
STE\ES A. Cott'rs HEADQ1 AVTEiz,
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C�,14 CARMEL FIRE DEPARTMENT
F6l.D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
rf (317) 571 2604 Federal ID#356000972
Patient Name: PIERCE, SHANNON
SHANNON PIERCE CARMEL FIRE DEPARTMENT
15536 SMITHFIELD DR 2 CIVIC SQUARE
WESTFIELD, IN 46074 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 03/17/17 990113428
Ticket# : 20161461:1
Date of Service: 3/19/2016
DETACH HERE
OVERPAYMENT RECEIVED. DUPLICATE PAYMENTS -PATIENT ON 09/30/2016 AND TRAVELERS
SENT A CHECK TODAY FOR$689.40. REFUND PATIENT$689.40
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20161461:1
Online Payment will charge a service fee.
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Charges
3/19/2016 *BASIC LIFE SUP PIERCE, SHANNON $675.00
3/19/2016 *MILEAGE PIERCE, SHANNON $14.40
---------------------------------
Charge Total: $689.40
Payments
Paid By. Invoice 03/19/16 $689.40
Paid By: PIERCE, SHANNON Payment 09/30/16 ($689.40)
Paid By: PIERCE, SHANNON COMMERCIAL INSURANCE 03/17/17 ($689.40)
Paid By: PIERCE, SHANNON REFUND 03/17/17 $689.40
BALANCE $0.00