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180794 12/30/2009 CITY OF CARMEL, INDIANA VENDOR: 363065 Page 1 of 1 t ONE CIVIC SQUARE JAMES DOWELL CHECK AMOUNT: $88.15 i, i CARMEL, INDIANA 46032 C/O PARKS ESE =„y„o CHECK NUMBER: 180794 CHECK DATE: 12/30/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1046 4230200 11.48 OFFICE SUPPLIES 1046 4343004 76.67 TRAVEL PER DIEMS Carmel 9 Clay Parks &Recreation Employee Expense Reimbursement Request Date of Fund Account Account Receipt Vendor listed on receipt Line Budget Description Amount Purpose of Expense 1 W C9 -e_ DT 0 y(0 i a6-tom LQ__` o 0 3 1. OW■ CA SL-00\ Qr I {,q€) Ias Ail receipts should be attached in the same order as listed above. No sales tax will be reimbursed. TOTAL: e I.,.?<o q r 7 7. Emp Name (print) G e S t n_. 1 I Address PI k 6=n '--e Dr-- DEC 2009 tj Check 11�� payable to: City, St, Zip I u F) )e3 Vi I e 1 `fi 11 L/ 6 Cab 0 T- i Aec/ Signature: 41. j Approved by: 4 Date: t Date: Business Services Division, Revised 7 -7 -08 FILE: Shared \Administrative \Forms\Staff Forms\Employee Exp Reimb Request PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM HO. 161 (1966] MILEAGE CLAIM TO o-m e3 bo we 1 (GOVERNMENTAL UNIT) ON ACCOUNT OF APPROPRIATION NO FOR (OnICP, BOARD, DF3ARTMEHr OR INSTITUTION) DATE FROM TO 1 SPEEDOMETER READING 4. AUTO MILEAG c 2. CCI NATURE OF BUSINESS POINT POINT I START TRAVELED PER MILE --__y_ i Sul 1= ms' i� :1 -3 MI IIIIMIIMIIIII=e11111111• f r =f ram Imo' I•= I I WM= 111•1111111 =MIN MIME i i .k 111•1111•11111 MINIM MIME NIMMIIIII t l t t I- I� IIIMIIIVI iti M� ��i� 111•111111111111M1111 ce_. 1.111111111111 MINIM 12 mmommommmimmoi l 111 W a MIMI =M =I I Ii MI MINIS I PAM AUTO LICENSE NO TOTALS I I ICI t`, 7 E) E)-/ SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map. 1 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 end that no part of the same has been paid. Date 3 c 3 n©�I z-il z D EC 0 rip— L \c 9 pi 0 (e 3 °4 1 h 1 2009 b ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of 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. Payee Purchase Order No. 363065 Dowell, James Terms 14328 Banister Dr Noblesville, IN 46060 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) PO Amount 12/8/09 Reimb. Office supplies 11.48 12/1/09 Reimb. Mileage 11/2 11/30/09 76.67 Total 88.15 I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and 1 have audited same in accordance with IC 5- 11- 10 -1.6 20 Clerk Treasurer Voucher No. Warrant No. 363065 Dowell, James Allowed 20 14328 Banister Dr Noblesville, IN 46060 in Sum of 88.15 ON ACCOUNT OF APPROPRIATION FOR 104 Program Fund PO# or Board Members INVOICE NO. ACCT #/TITLE AMOUNT Dept 1046 Reimb. 4230200 11.48 I hereby certify that the attached invoice(s), or 1046 Reimb. 4343004 76.67 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 23 -Dec 2009 i Y..%e%�?.7/2/ Signature 88.15 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund