328752 08/14/18 +pr_GAgM
�/ �. CITY OF CARMEL, INDIANA VENDOR: 372677
ONE CIVIC SQUARE CLYDE CHILDERS CHECK AMOUNT: $*****1,075.00*
s. aa: CARMEL, INDIANA 46032 12757 KIAwAH DR. CHECK NUMBER: 328752
gy`,�TON.�` CARMEL IN 46033 CHECK DATE: 08/14/18
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 MEM REFUND 1,075.00 MEMBERSHIP REFUND
Prescribed by state Board of Accounts City Form No.201(Rev.1995)
VOUCHER NO. WARRANT NO.
Vendor# 372677 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
CLYDE CHILDERS IN SUM OF$ CITY OF CARMEL
12757 KIAWAH DR. 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.
CARMEL, IN 46033
Payee
$1,075.00
Purchase Order#
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Course Terms
Date Due
PO# ACCT# DATE INVOICE# DESgR112j,10N
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# ( note attached invoices) 'll(s)) AMOUNT
C Childers $1,075.00 1 hereby certify that the attached invoice(s),or 8/3/18 C Childers Refund Membership $1,075.00
101 1207 101
S
bill(s)is(are)true and correct and that the
materials or services itemized thereon for
'�r;('yr(Q
which charge is made were ordered and
received except
Friday,August 03,2018
I hereby certify that the attached invoice(s),or bill(s),is(are)true and correct and I have
audited same in accordance with IC 5-11-10-1.6
, 20—
Cost
20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
• �. Fred 0.Buticr,M.D. Nir►j C3uPla,M.D.
e cStelihen Vii:Schtdta,'M.D. Sriclh�r E ,130113,?V111),
. ._ ;tephen 1'.f 1-adi Hayek,M 1).
Ashwiat�+:�t irdevamurlhy,M.D.
of Inditann UX W.-telice linkited to Hematology & Oncology
July 30,2018
To whom it may concern,
Clyde Childers has been under my care for cancer since 10/7/14. He is currently undergoing treatment and is
unable to participate in physical activities. Please feel free to call me with any questions at 317-228-3393.
Sincerely,
Niraj Gupta MD
Note generated: 07/30/2018 10:17 AM
Niraj Gupta MD
Document electronically signed by: Niraj Gupta MD
8301 Harcourt Rd,Suite 205,Indianapolis,IN 46260 a(317)225-3393•
100 Hospital Lane,Suite 320,Danville,IN 46122•(317)745-3752•
1706 Lafayette Road,Crawfordsville,IN 47933•(765)361-3000•1111 North Ronald Reagan Parkway,Suite B-1500,Avon,IN 46123•(317)217-2244
13430 North Meridian Street,Suite 204,Carmel,IN 46032•(317)228-3393
Name: Clyde Childers DOB: 06/08/1940
5301 Hucoutt Rd,Suite 205.Indimmlialis.IN 462$0-(317)22&3393
100 Hospital Lane,Suite 320,Dmille,IN 46122•(317)7;,5-3752.1215 Had1FyRoad, dte205,htoars-villa IN4058-(317)354-1700
170d Lai yette Rand.Crawfazdiville.IN 47933•(7d5)361-3000-I Ill Narth Ramld Rean lhskw ay.Suite H-1500.,Zva3LIN 4512 3-(31-)217-2244
13430 Nanh-Ve idian Strs=t.Suite 204.C==1.IN 46032.(3 17)225-3393
Childers, Clyde
RECEIPT REPRINT
Brookshire Golf Club
12120 Brookshire Pkwy
Carmel, IN 46033
Ph:(317)846-7431
Tuesday, December 20, 2016 10:58:29 AM
RECEIPT #:382293 User:Proshopl
----------------------------------
Item # List Pr. Disc %
Description Total
Qty Price
---------------------------------
1392
Season Pass (senior Single) Carmel Resident
1 $1,100.00 z $1,100.00
1406
Season Pass (returning Holder) Discount
1 ($125.00) ($125.00)
1006
Gift Card - Issued
XXXX-XXXX-XXXX-0795
Approval:591259
Ref:4334 100.00
1 $100.00 $
--------------------
Grand Total: $1,075.00
****Visa: $1,075.00
Change: $0.00
Credit Card #:xxxx-xxxx-xxxx-3256
CLYDE CHILDERS
Approval Code:05016C Exp:XX/XX
Reference #:3686
Thank you for playing Brookshire Golf Club!!
In case of severe weather or lighting, play at
your own risk!
NOW BOOK ONLINE @ www.brookshiregolf.com
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1111 ILII