314063 7/26/2017 CITYOF CARMEL, INDIANA VENDOR: 371523 .......
CHECK AMOUNT: $ 300.00'
ONE CIVIC SQUARE MARLENE MILLER
: ao CARMEL, INDIANA 46032 13718 ROSWELL DRIVE CHECK NUMBER: 314063
,M CARMEL IN 46032 CHECK DATE: 07/26/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 07 .24 . 17 300.00 OTHER EXPENSES
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City of Carmel Employee Health Benefit Plan
Health Savings Account Incentive
The retired plan participant listed below has elected Plan A for 2017 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:
Marlene Miller
13718 Roswell Drive
Carmel,IN 46032
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: July 24,2017
Subrnl`ted To
JUL 2 5 2017
Clerk Treasurer