180771 12/30/2009 ,4,177,-1,N.„., CITY OF CARMEL, INDIANA VENDOR: 361017 Page 1 of 1
ONE CIVIC SQUARE JENNY CHASTAIN CHECK AMOUNT: $31.90
\s. CARMEL, INDIANA 46032 511 SECOND AVE NE
CARMEL IN 46032
z. CHECK NUMBER: 180771
CHECK DATE: 12/30/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1160 4343004 31.90 TRAVEL PER DIEMS
Claim No. Warrant No. I have examined the within claim and hereby
IN FAVOR OF certify as follows:
That it is in proper form.
That it is duly authenticated as required
by law
That it is based upon statutory authority
That it is apparently
correct
incorrect
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Disbursing Officer
On Account of Appropriation No. for
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A.E. BOYCE CO., INC. MUNCIE. IN 0II36 2 8 a
PRESCRIBED BY STATE BOARD OF ACCOUNTS
GENERAL FORM NO 101 (1986)
MILEAGE CLAIM
TO
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(GOVERNMENTAL UNIT)
L.. ON ACCOUNT OF APPROPRIATION NO. FOR
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(OFFICE, •ARD, DEPARTMENT/ID; INSTITUTION)
DATE
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READING NATURE OF BUSINESS MILES 5S
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PER MILE
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AUTO LICENSE NO. TOTALS 3/ a
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits
and that no part of the same has been paid.
Date 0 2/l i fi r 's