314049 7/26/2017 ♦�ar C,,N,�E?
CITY OF CARMEL, INDIANA VENDOR: 114500 CHECK AMOUNT: $*******400.00'
ONE CIVIC SQUARE TIMOTHY J. GREEN
CARMEL, INDIANA 46032 11468 SENIE LANE CHECK NUMBER: 314049
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CARMEL IN 46032 CHECK DATE: 07/26/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTIOTHER EXPENSESON
301 5023990 07 .24 .17 400.00
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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:
Timothy Green
11468 Senie Lane
Carmel,IN 46032
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: July 24,2017
Subm ="ted To
JUL 2 5 2017
Clerk Treasurer