HomeMy WebLinkAbout332439 11/21/18 �d CAAM
CITY OF CARMEL, INDIANA VENDOR: 355473
`/ `` ******** *
.I, ® , ONE CIVIC SQUARE DAREN MINDHAM CHECK AMOUNT: $ 89.00
:. i'; CARMEL, INDIANA 46032 14118 WARBLER WAY NORTH CHECK NUMBER: 332439
'M,iTON�p� CARMEL IN 46033 CHECK DATE: 11/21/18
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1192 4341999 REIMB 89.00 OTHER PROFESSIONAL FE
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
Vendor# 355473 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
DAREN MINDHAM IN SUM OF$ CITY OF CARMEL
14118 WARBLER WAY NORTH 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
$89.00
ON ACCOUNT OF APPROPRIATION FOR Purchase Order#
Dept of Community Service Terms
Date Due
PO# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
Mindham 43-419.99 $89.00 1 hereby certify that the attached invoice(s),or 11/14/18 Mindham CDL Physical required by Street Dept- $89.00
1192 101 1192 101 Mindham
bill(s)is(are)true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
Friday, November 16,2018
Mike Hollibaugh
Director
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
a�
RECEIPT
Community Employer Health Solutions Carmel
11911 N.Meridian St.,Ste.160
Carmel, IN 46032
(317)621-6704
Account Name: Self Pay Date: 11/14/2018
Received from: Daren Mindham Payment Type: Visa
For: AOT Physical Amount: $89.00
Reference#:
Description: Visa-Co Payment-Visa Received by:
Payor Copy
RECEIPT
Community Employer Health Solutions Carmel
11911 N.Meridian St.,Ste.160
Carmel, IN 46032
(317)621-6704
Account Name: Self Pay Date: 11/14/2018
Received from: Daren Mindham Payment Type: Visa
For: DOT Physical Amount: $89.00
Reference#:
Description: Visa- Co Payment- Visa Received by: �
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Patient Birth Date: 08/25/1977 Invoice#:
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