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CI.,TY OF CARMEL
ZONING/ DEVELOPMENTS RECEIPT
********************************************************************************
PARCEL ID
PROJECT
RECEIPT #
1609360002004005
08020004
27537
03/04/2008
RECEIPT DATE
RECEIVED BY
REC'D. FROM
TEST106.1
UDF 106.2
NOTES : CLARIAN HEALTH/VELOCITY ADLS
scoy
CLARIAN HEALTH
FEE ID
UNIT QUANTITY
P-ADLSAMS
SIGN 1.00
TOTAL PROJECT ;
METHOD OF PAYMENT
AMOUNT
CHECK
TOTAL RECEIPT ;
3 42 . 0 0
342.00
ADDRESS
PRINT DATE
PRINT TIME
OPERATOR
COpy # :
CASH DRAWER:
1402 CHASE CT
03/04/2008
08:58:30
scoy ~'--
1
PZ
AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ---------- ----~--~-- --------_.-
342 00 0 00 342 00 0 .00
---------- ---------- ---------- ----------
342 00 0 00 342 00 0 .00
NUMBER
412914
FEB-}9-2008 rUE 08:59 AM
FAX NO. p, 02
City of Carmel
One Civic Square
Carmel, IN 46032
317.571-2417 fax 317-571-2426
Invoice No. 106
-
INVOICE ~
.Cuslom&r
Name Clarj~~_,tl~alth j Velocil'L Sports Signage
Address 1402 Chase Ct.
City Carmel State IN ZIP 46032 .
Phone
Da1e
Order No.
Rap
FOB
2J13/200S
f
~
CfJYJI ~
atl
-
~R!ion.__ Unit Price TOTA.L
~... ,
lee $285.00 $285.00
$57.00 $57.00
ayment.
0:
Tot.ll_ $342.00
"- SO.OO
Desc
ADLS Amendment applicatIOn
Fee per sign
Please return one copy with p
Please make check payable t
City of Carmel
and mail to the attention:
City of Carmel, DOCS
Orrs Civic Square
Carmel. It>! 46032
Payment Details
o Cash
o . Check
I.Qtfice Use Only~
I
City of Carmel, Deparlment of Community Services
Received Time Feb.19. 9:36AM
'P" ~
y
<;;\~\J- / ~~
(}QJ 9 \\- ~ '
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Vendor Payment Request
Page 1 of ]
~1 If Clarian Health
; Methodist .IU. Riley
This form is not to be u~ed to payor reimburse employees
Vendor Pllyment Request
Number: 17574
Duc Date: 102-22-08
I--~~---
Date: 102-19-08 l
At. tach all supporting J
documents
Remit to:
Nrtme
City of Carmel
Payee lnfomiation
1.15 payment for Services, A wards, Rents, Royalties or Medical Service?
G 'Y"es' Provide Taxpayer Identification Numberrequested in question 2
below.
(!, No Go to question 3 below
2. Enter payee Taxpayer Identification Numbtir, ifrequired, .
Social Security No, [----------------] OR .Employer LD Number r..-.....--.'.-'-l
3, Is payee a non resident alien?
c- Yes Please comply with section 11 on reserve side.
co: No Go to next section of form.
Addrr:.ss
One Civic Square
City
Carmel
State
Indiana
Zip
46032
Special Instructions:
....-...."....,...... -...-.--.----"'--.---, .. .........-....-....-,......-..-.. ..--------...--..-....----...- ~-....---........_-..--..-..... ..--- -----.-. .... - - - AIll) 1'I'lffi)jJ'f{-" .u___ ----.---.8
SlHI.:UAl[)
02/26/200n J
1
......._.............._._...___._..._...___.~____...__....._..__._..._..______~~___._. .._u...,______.......__..______..u__......._..... _____ _ _.. ..~, ....__ .___._.__._.__u _ _ ____ .__ _ _~___d
Company Paying Expense(Please check one)
Company 10 Company 20. Company 30
[7110 CHP C 20 MMGP C 30 MOHC
r::: 15 C1arian C 23 ~1(VIG r: 34 UCON
Home Care 025 HMS
Number of lines' to enter: I__J : UPdat~
Description Accounting Unit
ADLS Amendment application 101015
fee fOf CH/VSP signage
. Company 40
r:- 40 M-Plan
C 45 Encore-PPO
C 60 HealthNet
l 80 EMGI
r- 100 Methodist
Health Foundation
I. Other 1_ .. __. __.
GfL Account
Amount
73110
. 342.00
Payment Total
342.00
Prepared by: !Aimee Lacey
-- "'I
I
Department Phone#: ~6-~~~~3~-"~--- -=:J
I (we) have revieweo the r~quest and unoerlying documentation and hereby' certify that it Is appropriate use of funcJs (either
restricted or umestricted) consistent with the intern and written guidelines whi~h have been established for the use of those
funds and the tax..exempt purpose of the Organization. I ilm authorized to ilpprove expennitures from this Fllnd or Cost Center.
Print Name: ~~~ila~-og~~_~=~___._._=-~~
r~'-"-----"'''--' ..-....,.....-- ... ...-.- .-..-.......... ...---...-....-.--.........~.
Title: 6dministrative Director Of._?~ho.l?~ed,
Signatur~; ..,Jl ~~W 'r ~
Date: I02~'1'9-~03--- --. ..!
(~.._.___.~ ..__ _....., ,_~. ... L., _ ,.________.__
http://pu1se. clar'ian. org/F orrnsm tmllvendorPayrnentReq uest Print.j sp
2/19/2008