180879 12/30/2009 CITY OF CARMEL, INDIANA VENDOR: 360618 Page 1 of 1
14,577-, ONE CIVIC SQUARE STEPHANIE MARSHALL
CARMEL, INDIANA 46032 578 TULIP POPPLUR CREST CHECK AMOUNT: $283.38
CARMEL IN 46033
o CHECK NUMBER: 180879
CHECK DATE: 12/30/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4347500 283.38 GENERAL INSURANCE
0
Richard Marshall, Jr. 0 SVP Worldwide COBRA Coupon #2 October/2009
Coverage Tier Period Premium
BCBS HDHP/I-ISA Medical Plan Employee 1- Family 10/01/2009 10/31/2009 310.68
Della Dental Plan Employee Family 10/01/2009 10/31/2009 22.71
Comments Notes: Subtotal: $333,39
Amount Paid: $0.00
Return this Coupon and Your Payment to: Coverage for Total Due: $333.39
Medcom Richard Marshall, Jr. Due Date: 10/01/2009
P.D. Box 10269 Total Enclosed. 0373
Jacksonville, FL 32247-0269 578 Tulip Poplar Crest
Carmel, IN 46033 Make Check Payable to
Medcom
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A Division of Webster Bank,N.A_
P.O. Box 939
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Richani C Marshall Jr
578 Tulip Poplar Crest
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HSA ACCOUNT
4,167.13
gi Mii i itc ,1 1Pq.P•RA:7:: :i
3,833.74
10/07/2009
BALANCE LAST STATEMENT 09/30/2009
333.39
DISTRIBUTION/WITHDRAWAL CHECK #105
3,837.04
3.30 10131/2009 INTEREST PAID
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ANNLJAL INTEREST EARNED DURING CYCLE PERIOD CURRENT INTEREST RATE o 99%
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BAN K HSA Bank® is a division of Wehsier Bank, N.A., Member
Prescribed t y State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
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.
Payee
5fo/✓47//= qr5 ‘91 Purchase Order No.
5 7.6 4 C/ Terms
//1- 2 3. 3 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
&/o //9 %v a) 7 O /74'Q /4I 7/77se/721ve s" d 3g
Total 283 3.8.
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
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
4,4" IN SUM OF
578 7 /i,. Ao4r
/JlJ
251. -3g
ON ACCOUNT OF APPROPRIATION FOR
���y3y7s
Board Members
DEPT.
Po# r INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify Y
that the attached invoice(s), or
9 2 /d 7 '975 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
/2 —2/ 20
Sig ature
Director of Opt~ tons
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund