314802 08/15/2017 uf.4�qM
CITY OF CARMEL, INDIANA VENDOR: 061 155 CHECK AMOUNT: S*******180.00*
ONE CIVIC SQUARE CLERK OF COURTS ANNUAL FEE
CARMEL, INDIANA 46032 PEP OX 6 6s CHECK NUMBER: 314802
INDIANAPOLIS IN 46260-6069 179
CHECK DATE: 08/15/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1180 4355300 17805 180.00 ORGANIZATION & MEMBER
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Invoice for Payment by Check
Your payment has been initiated.Please print this page twice:one copy for your records and one to turn in with your payment. Failure to include
a copy of this Invoice with your payment may result in your payment not being credited to your account.A copy of this information has been
emailed to you.
Confirmation #: 17805
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Fees (Transaction processed at 1:37:27 PM EDT, 7/31/2017)
Douglas Haney(11207-49) Annual Fee $180.00
Total Due $180.00
Instructions
For payment by check IMPORTANT:Write your confirmation number on the memo line of your check.
Write your confirmation number(see below)on your check,and then mail or
deliver your check,along with a printed copy of this Invoice,to:
Clerk of the Courts-Annual Fees John Q.Polk 1234
123 Main Street
P.O. Box 6069—Dept. 179 S:rtln There,Indiana 4f m4
017,1 155•555f5 Date
Indianapolis, IN 46206-6069
���� Cterk of the Courts-Annua! Fees �$
Your payment will be recorded as of the postmark date on the envelope
OLnr�RS
containing your full payment. Late tees will be due if full payment is not timely i Amoua:
submitted. namo Confirmation#
For payment in cash ; 1:0000742581: 88963423»• 1234w
Cash payments may be personally delivered,in exact change only,with a
copy of this Invoice between 8:30 a.m.-4:30 p.m.on regular business days to
the following location:
Clerk of the Courts
402 W.Washington St., Rm.W062
Indianapolis, IN 46204
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https:Hsecure.in.gov/apps/courts/portal/payment/summary 7/31/2017