314070 7/26/2017 y�,4'""f. CITY OF CARMEL, INDIANA VENDOR: 00351023
"= JACE PLATT CHECK AMOUNT: $"**....300.00*
ONE CIVIC SQUARE 4636 ROYAL OAK LANE CHECK NUMBER: 314070
?a CARMEL, INDIANA 46032 CARMEL IN 46033 CHECK DATE: 07/26/17
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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:
Jace Platt
4636 Royal Oak Lane
Carmel, IN 46033
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: July 24,2017
Submitted To
JUL 2 5 2017
Clerk Treasurer