HomeMy WebLinkAbout315657 8/31/2017 CITY OF CARMEL, INDIANA VENDOR: 359016
�.; CHECK AMOUNT: S"""""""150.98'
ONE CIVIC SQUARE KAREN BREEDLOVE
a`. CARMEL, INDIANA 46032 1409 HANNIBAL STREET CHECK NUMBER: 315657
�y NOBLESVILLE IN 46060 CHECK DATE: 08/31/17
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 20171081215 150.98 OTHER EXPENSES
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Invoice Page 1 of 1
71-��-, JotForm
Invoice
JotForm Inc.
Date Invoice#
1750 Montgomery St April 18th, 2017 20171081215
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To Ship To
Username: Backflow Username: Backflow
Name: City of Carmel Backflow Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov Email: Backflow@carmel.in.gov
Services Total
JotForm Bronze Monthly $19 USD
Amount Due: $19 USD
(91Y
DELIVERED AUG 1.4 209
https://www.j otform.com/invoice?u=Backflow&id=2017-04-18_00:15:15 6/21/2017
Invoice Page 1 of 1
Joll."Orm
Invoice
JotForm Inc. Date C Invoice #
1750 Montgomery St April 25th, 2017 20171150102
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To IShip To
Username: Backflow Username: Backflow
Name: City of Carmel Backflow Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov Email: Backflow@carmel.in.gov
Services Total
Remaining time on Silver Monthly after 25 Apr 2017 $29.21 USD
Unused time on Bronze Monthly after 25 Apr 2017 - $14.23 USD
Amount Due: $14.98 USD
r
DELIVERED AUG 14101
https://www.jotfonn.com/invoice?u=Backflow&id=2017-04-25_13:02:03 6/21/2017
Invoice Page 1 of 1
JotForm
Invo><ce
JotForm Inc. Date Invoice #
1750 Montgomery St IMay 18th, 2017 20171381215
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To IShip To
Username: Backflow Username: Backflow
Name: City of Carmel Backflow Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov Email: Backflow@carmel.in.gov
Services Total
JotForm Silver Monthly $39 USD
Amount Due: $39 USD
U501
7 1 '
MWERED AUG Tse 2W
https://www.jotform.com/invoice?u=Backflow&id=2017-05-18 00:15:18 6/21/2017
Invoice Page 1 of 1
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Jortworm
Invoice
JotForm Inc. Date Invoice#
1750 Montgomery St June 18th, 2017 20171691215
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To IShip To
Username: Backflow Username: Backflow
Name: City of Carmel Backflow Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov Email: Backflow@carmel.in.gov
Services Total
JotForm Silver Monthly $39 USD
Amount Due: $39 USD
C�
DELIVERED AJu 1.4 ZW
https://www.j otfonn.com/invoice?u=Backflow&id=2017-06-18_00:15:52 6/21/2017
8/7/2017 Invoice
7,- JotForm
Invoice
JotForm Inc. Date F Invoice#
1750 Montgomery St July 18th, 2017 20171991216
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To Ship To
Username: Backflow Username: Backflow
Name: City of Carmel Backflow Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov Email: Backflow@carmel.in.gov
Services Total
JotForm Silver Monthly $39 USD
Amount Due: $39 USD
Ce
DELIVERED AUG 1A 1011
MtpsJ/www.jotform.canlnvace%=Backflow&jd=2017-07-18_00:16:42 1/1
Date Description Withdrawal Deposit Category Balance
-July
JL.'1.' KXXXX'211),:1:I 'R[" flll' 1�, 7
XXXXX78 15 CA
June
"If:, Vf -X)(XXX"I,`) ienSr 7?
XXXXX731 5 CA
T, 4;:C: 't xxxxx'-1 F,CA
821/2017 Invoice
Jo
r
Form
Invoice
Invoice#a
JotForm Inc. Date;
- —
1750 Montgomery StJuly 18th,2017: 20171991216'
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To Ship To
Username: Backflow Username: Backflow
Name: City of Carmel Backflow 1 Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov 'Email: Backflow@carmel.in.gov
Services Total
JotForm Silver Monthly $39 USD
Amount Due: $39 USD
https:Dwww jotform.comfinvace'hu--Backflaw8ioi=2017-07-16 00:16:42 111
Date Description Withdrawal Deposit Category Balance
-July
Ju119 -XXXXX3200JCTFORKI INC S3+00 Personal+-amih+ -Sill 73
XXXXX7615 CA
va7 appear or;tor staterer'as
DEBIT CARD PURCHASE XXXXX167'JC'T=(DR1.1 INC XXXXX7615 CA
-June
Jun 19 -XXXXX3170 JOTFORRI INC 00 Entertainment gC)73
XXXXX7815 CA
DEBIT CARD PURCHASE XXXXXI5W'JOT=OP,IJ INC XXXXX7815 CA
Transactions older than Jun 19 are located in online ;raterr n"s
if *2017 Invace
JotForm
Invoice
JotForm Inc. Date; Invoice#
1750 Montgomery St June 18th, 2W,120171691215:
__..__.
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To Ship To
Username: Backflow ! Username: Backflow
Name: City of Carmel Backflow 1 Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov Email: Backflow@carmel.in.gov
i
Services Total
JotForm Silver Monthly $39 USD
Amount Due: $39 USD
Mtpsl/www.jotform.cominvace?Lr-Backflow&X=2017-06-18 00:15:52 1/1
Virtual Wallet With Performance Spend Statement
For the perlod 041251E017 to 05@312017
Ea For 24-hour inforrnation,sign on to PNC Bank Online Banking MICHELLE BREEDLOVE
on pnc.com Primary account number: 46-3060-1116
Account Number: 46-3060-1116 -continued Page 5 of 6
Banldng/Che&Card Withdrawals and Purchases -continued
Date Amount Description
05/16 26.56 1873 Debit Card Purchase Wendys-Tfl#3011
(1074
05/17 10.31 1873 Debit Card Purchase Arbys 6357
Noblesvill
05/17 33.72 POS Purchase Big Lots Store Noblesville
05/18 24.98 1873 Debit Card Purchase Shell Oil
57444344907
05/18 32.67 1873 Debit Card Purchase Donatos Pizzeria
#0318
05/18 15.01 1873 Debit Card Purchase Shell Oil
57444344907
05/18 20.62 1873 Debit Card Purchase CVS/Pharmacy
#01367
05/19 39.00 1873 Debit Card Purchase Jotform Inc.
.8►�'?017 Invoice
JotForm
Invoice
JotForm Inc. _ Date; Invoice#
1750 Montgomery St May 18th, 2017;20171381215'
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To Ship To
Username: Backflow Username: Backflow
Name: City of Carmel Backflow Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov Email: Backflow@carmel.in.gov
i
3
Services Total
JotForm Silver Monthly $39 USD
Amount Due: $39 USD
https:/Mrww jod&m.comAnvoice?u=Backflow&X=2017-05-18 00:15:18 1/1
There were 6 Check Card
gank card
PIN POS purchases
totaCheck Card and Purchases $351.20.
ganldn9� Amount Description dots Stores- There were 88 other Banking
pate 1873 Debit Card Purchase Big Machine/Check Card deductions
04125 204.65 #511totaling$2,445.55.
366.98 1873 Debit Card Purchase Meijer IGUe30 en
04125 5.97 1873 Debit Card Purchase Dairy
04125 #11785 le*Ma
99 1873 Debit Card Purchase Google
04126 g.colpayhe Speedway 05179
23.24 1873 Debit Card Purchase
04126 10T
rd Purchase Jotforrn Inc.
14.98 1873 Debit Ca
04126 -- --- -
8/21/2017 Invoice
i
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Invoice
JotForm Inc. DateInvoice
'; - #
1750 Montgomery St Apri125th, 2017 20171150102'
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To { Ship To
i
j Username: Backflow Username: Backflow +
Name: City of Carmel Backflow ;Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov ;Email: Backflow@carmel.in.gov
s
Services Total
Remaining time on Silver Monthly after 25 Apr 2017 $29.21 USD
Unused time on Bronze Monthly after 25 Apr 2017 -$14.23 USD
Amount Due: $14.98 USD
https://www.jotform.comfinvace?u=Backflav&d=2017-04-25 13:0203 1/1
BWtldrWCl 1**Card Wiftrawsk aW Rudma -cbnhnued
Date AMCUM DeSOPUM
04/17 5.72 1873 Debit Card Purchase Starbucks Store
02664
04117 35.75 1873 Debit Card Purchase Perfect Nails
04/17 38.21 1873 Debit Card Purchase Pizza King- 82
04/17 23.00 1873 Debit Card Purchase Speedway 05179
10T
04/17 26.80 POS Purchase R K Oil Corp Noblesville
04/17 27.68 POS Purchase CAIS/Pharmacy #Carmel In
04/18 3.54 POS Purchase CVS/Pharmacy#Carmel In
04119 19.00 1873 Debit Card Purchase Jotform Inc_
821/401T Invoice
Jo tForm
Invoice
JotForm Inc. Date; Invoice#
1750 Montgomery St ; April 18th, 2017:F0171081215
San Francisco, CA 94111
Tax ID: 46-5729519
Bill To
Ship To
ij Username: Backflow Username: Backflow
'Name: City of Carmel Backflow 1 Name: City of Carmel Backflow
Email: Backflow@carmel.in.gov Email: Backflow@carmel.in.gov
s
Services Total
JotForm Bronze Monthly $19 USD
Amount Due: $19 USD
httpsl www.jakform.comfirnace?u=Backflow&jd=2017-04-18 00:15:15 1/1