309876 04/04/17 �''� .c�,,,f. CITY OF CARMEL, INDIANA VENDOR: 358941
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ONE CIVIC SQUARE PETTY CASH -BROOKSHIRE GOLF COURdjCK AMOUNT: $ 49.47
s ?Q; CARMEL, INDIANA 46032 C/O PAM LISTER CHECK NUMBER: 309876
'����ON,4p CHECK DATE: 04/04/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 COSBY 49.47 ORGANIZATION & MEMBER
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41situi i welcome w moiana ucensing
Indiana _
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This page serves as your receipt for this transaction. Your payment will appear on your credit card
statement as "STATE OF IN WWW INGOV 800-236-5446 IN".
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Payment received -thank you.
Licensee: matthew I cosby
License Number: Pending
Authorization Code: 611782
Received Date: 4/3/2017 10:46:15 AM
Transaction ID: 72842802
Credit Card Number: XXXX XXXX XXXX 0995
Fee Amount: $45.00
Enhanced Fee: $2.50
Instant Fee: $1.97
Total Payment: $49.47
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