314078 7/26/2017 ,;, CITY OF CARMEL, INDIANA VENDOR: 00350917 CHECK AMOUNT: $""k k k k k4D0.00"
ONE CIVIC SQUARE KIM ROTT CHECK NUMBER: 314078
1303 HOLLYCRES:; r°; CARMEL, INDIANA 46032 BLOOM INILT61R101 CHECK DATE: 07/26/17
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DESCRIPTION
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301 5023990 07 .24 .17
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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:
Kimberly Rott
1303 Hollycrest Drive
Bloomington, IL 61701
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: July 24,2017 Subm:llfted To
JUL 2 5 2017
Clergy: Treasurer