180934 12/30/2009 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
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ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK AMOUNT: $80.00
aM INDIANAPOLIS IN 46204 CHECK NUMBER: 180934
CHECK DATE: 12/30/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4340702 12168 80.00 SHOTS INOCULATIONS
INVOICE
Public Safety Medical Services
324 E. New York Street
E Suite 300
Ix Indianapolis, IN 46204
Carmel Fire Department CARMEFD
I 2 Civic Square Terms
Carmel, IN 46032 Invoice Date 12/09/2009
m Invoice 00 -12168
Date Employee Description Amount Balance Due
11/30/09 Platt, Jace P. Hepatitis B Vaccination #2 $70.00 $70.00
Injection Fee $10.00 $10.00
Total Charges $80.00
Total Payments Balance Due $0.00 $80.00
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from invoice
date
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF$
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$80.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# /Dept. INVOICE NO. ACCT #TTITLE AMOUNT Board Members
1120 12168 43407.02 $80.00 I hereby certify that the attached invoice(s), or
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
DEC 2 _1 2009
I F A f
1 '1
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Prescribed by 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
Purchase Order No:
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12168 $80.00
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