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314087 7/26/2017 CITY OF CARMEL, INDIANA VENDOR: 00350735 ONE CIVIC SQUARE BOB VANVOORST CHECK AMOUNT: S*"*****400.00* 4> =Q CARMEL, INDIANA 46032 23402 MULE BARN ROAD CHECK NUMBER: 314087 +.y. SHERIDAN IN 46069 CHECK DATE: 07/26/17 aroM c� DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 301 5023990 07.24.17 400.00 OTHER EXPENSES n ® U = $ « _ a m g O # O \ � # 2 m / � o o \ # 2 f 0 / / E , y c 2 00 0 % 2 $ / \ Q Q % $ Cl) q I E Z % , M ® ƒ ƒ b 3 ƒ � � � $ v 0 a g $ -n > - - 0 \ § k \ jco S CL a D & 2 w § z 2 7 > -n O / \ \ q £ § | \ . } & a 7 g z > _ % 0 (Dp i % { ƒ / \ ? 2 CD { a 0 k v w A 2 2 E f R _ CD m # « E g § 0 2 / CD $ 2 + - E CD \ C ƒ % 3 2 K 0 CD ƒ $ 0 k k 09- a a - C cu & 2 k \ \ / G , , a E Z § - ± ƒ § o [ k « / q o C f ƒ a 9 f > 0 k� \ ƒ d m CD \ � ; _ 2 k E D $ ) \ 0 7 § \ q c \ � k o 0 w z - gƒ ° ° q ƒ C o ) J k z § k \ \ CO �< 70 } D }_¢ CDD E � 0 U,\ � n j E CD c \ \ E ¥ 2 \ ] i E ; C % CD / E §} CD q B k 2 _� $ 8 mCL ] CD k z ) § CL > © { £ § . / $ 8 § k \ 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: Robert VanVoorst 23402 Mule Barn Road Sheridan, IN 46069 Amount: $400.00 Fund: Medical Escrow Fund (301) Date: July 24, 2017 Submitted To JUL 2 5 2011 Clerk Treasurer