314055 07/26/17-VOIDED ��'"' CITY OF CARMEL, INDIANA VENDOR: 354969
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ONE CIVIC SQUARE MATTHEW HOFFMAN CHECK AMOUNT: $*******400.00*
:? �4 CARMEL, INDIANA 46032 5808 SEDGEGRASS CROSSING CHECK NUMBER: 314055
CARMEL c�, CARMEL IN 46033 CHECK DATE: 07/26/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 07.24 .17 400.00 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:
Matthew Hoffman
5808 Sedgegrass Crossing
Carmel,IN 46033
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: July 24,2017
Submi*ted To
JUL 2 5 2017
Clergy: Treasurer