HomeMy WebLinkAbout315232 08/29/2017 CITY OF CARMEL, INDIANA VENDOR: L2370 CHECK AMOUNT: S'""""'"275.00'
I N S C C U-ASFE
ONE CIVIC SQUARE Po sox 6271 CHECK NUMBER: 315232
=Q; CARMEL, INDIANA 46032 INDIANAPOLIS IN 46206-6271 CHECK DATE: 08129117
DESCRIPTI
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT OTHER EXPENSESON
101 5023990 275.00
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Forth No.201(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee4 Y1 T' 3
1 U 1 �5�� Purchase Order No.
Po ?j ox (OW)1i Terms
M'�& `J �+ Date Due o&a
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
n
7 MT W
CID
C t�lf'(13':
vLb
�'
Total A15`0
hereby certify that the attached invoice(s)"orbill(s), is (ar true correct a I e audited same in accor-
dance with IC 5-11-10-1.6.
20
Clerk-Tr surer
THE EMPLOYEES LISTED BELOW OWE THE 2017 INDIANA ANNUAL SUPPORT FEE.
• The remittance for the Annual Support Fee must be mailed separately to the special ASFE P O Box address listed
below.
• You are not obligated to make a payment for emp I oyees/i n come payees listed if he/she is no lonuer employed by your
company. If there is an outstanding paycheck,send the amount requested from the list below while not exceeding the
COPA limits. if an employee/income payee is not employed by your company,please complete column 3 of the list
and fax to(317)232-0290.
Please retain a copy of the completed list.for your records.ff additional or multiple
payments are needed,a copy of'this list is to he sent with your payments.
Employer Name: CITY OF CARMEL Make Check Payable to:
DBA: INSCCU - ASFE
FEIN: 356000972 P O Box 6271
Indianapolis 1N 46206-6271
Employee's Name Employee's Date of Last Day ISETS Case# Amount Amount
SSN Worked or Due Paying
Never Employed per case per case
CARTER,MARCUS L. 312-74-3975 ASFE3671874 $55.00
CASTANEDA,ALDWIN 307-19-2679 ASFE6635697 $55.00
DIALLO,AMADO T. 132-78-7902 ASFE7473904 $55.00
MARTIN,DAVID 315-58-4956 ASFE7682307 $55.00
NAVARRETTE,JUAN 564-95-8825 ASFE6841213 $55.00
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