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Home My WebLink About315657 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 F«ON DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 20171081215 150.98 OTHER EXPENSES � 2 , E @ } 2 % 2 } 444- U- 0 2 \ cl 3 2 « « � $ q k Ln Ln � � \ L k 2 O % Z� R � } ® 9r 2 } § ƒ \ @ 2 k \ _ V) CM LU U- LU E / a ° bcn � Ln 3 % k 2 k u M: 3 2 k 2 k % > ¢ 2 § 2 3 g toQ O n E % E \ Ln � Q . > n m D . a u 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 } 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 r Jo toren 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