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HomeMy WebLinkAbout181126 01/13/2010 CITY OF CARMEL, INDIANA VENDOR: 027850 Page 1 of 1 ONE CIVIC SQUARE JAMES BRAINARD CARMEL, INDIANA 46032 CHECK AMOUNT: $2,060.26 CHECK NUMBER: 181126 ti_ *oa CHECK DATE: 1/13/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1160 4343002 600.00 EXTERNAL TRAINING TRA 1160 4343003 1,460.26 TRAVEL LODGING U.S Conference of Mayors 78th Winter Meeting January 20 22, 2010 (REVISED with correct date) Capital Hilton Hotel Washington, DC REGIStli'TION FO (�No regis .ations will be processed without accompanyin_ payment) Name t' 0 Title rL 9 Organization Street A, dress �M City _J,.'/(1L State A. Y Ld y Telephon i �zarm Fax Jy -J= avj Email r�I Of /1 �;fr I Preferred Name on Badge (First Only) Gender dr Male male Attendee(s) has special needs: 0 Yes Ii No (If yes, USCM will contact.) Newly Elected: 0 Yes No First Time Attendee: 0 Yes k No Name of Accompanying Spouse /Partner (First) (Last) (There is no additional registration fee for spouses.) CONFERENCE REGISTRATION INFORMATION (No registrations will be processed without accompanying payment) Registration Fees: MEMBER NON MEMBER Early Registration Fee: 5600 51050 (Payable by December 30, 2009) Advance /On -Site Registration Fee: 5800 51300 (After December 30, 2009) Checks or purchase orders for payment of registration fees should be made payable to: The United States Conference of Mayors. Refunds will be made for cancellations received in writing by December 30 (less a $100.00 service fee). NO REFUNDS will be made for cancellations received after December 30, 2009. CREDIT CARD AUTHORIZATION: Please note by submitting your card information, you are authorizing USCM Meetings Department to use the card below to pay your registration fee. Please circle Credit Card Type: Other (Specify) Credit Card No. Exp. Date i dil!iii Signature i (USCM Only Authorization Code Date PLEASE RETURN THIS FORM WITH YOUR REGISTRATION PAYMENT TO: The United States Conference of Mayors Attention: Carol Edwards 1620 Eye Street, N.W., Washington, DC 20006 Telephone (202)293 -7330 Fax (202)467 -4276 PLEASE SEE REVERSE SIDE FOR HOTEL RESERVATION REQUEST FORM i,4 'fit the westin seattle J� er,, 1900 fifth avenue seattle, washington 98101 f r y r( phone 206.728.1000 fax. 206.728 2259 i i i3..., west in.comseattle ,,/l U tz guest travel agent /charge to room 2054 James Brainard rate 199.00 no. pers. 1 *'a..r 1 Civic Sq. folio 802602 EX -A Carmel, IN 46032 page 1 arrive 01- OCT -09 18:14 depart 04- OCT -09 UCI30A payment d, E efef a PrSCi e y Fr2SC[fY tQll i T R a C fSa gP2C gEs vs i "1:, 1: 01- OCT -09 RT2054 Room Charge 199.00 01- OCT -09 RT2054 State Tax 17.11 01- OCT -09 RT2054 Occupancy Tax 13.93 02- OCT -09 RT2054 Room Charge 199.00 02- OCT -09 RT2054 State Tax 17.11 02- OCT -09 RT2054 Occupancy Tax 13.93 02- OCT -09 8584 800 -837 -4089 0045 00:00 2.00 02- OCT -09 8584 Telephone Tax State 0.19 02- OCT -09 8586 800- 837 -4089 0004 00:23 2.00 02- OCT -09 8586 Telephone Tax. State 0.19 03- OCT -09 RT2054 Room Charge 199.00 03- OCT -09 RT2054 State Tax 17.11 03- OCT -09 RT2054 Occupancy Tax 13.93 03- OCT -09 3911 800 -837 -7372 0001 18:56 2.00 03- OCT -09 8911 Telephone Tax State 0.19 03- OCT -09 8912 800- 837 -4099 0001 18:57 2.00 03- OCT -09 8912 Telephone Tax State 0.19 03- OCT -09 8914 800 -837 -4089 0002 18:57 2.00 03- OCT -09 8914 Telephone" Tax State 0.19 03- OCT -09 9054 800-837-4089 0040 00:00 2.00 03- OCT -09 9054 Telephone Tax State 0.19 04- OCT -09 703.26 Balance Due 0.00 continued on the next page k* I agree to remain personally liable for the payment of this account if the corporation or other third party billed fails to pay par t or all of these charges. signature James Brainard FOLIO 802602 01- OCT -09 \VEST HOTELS RESORTS the westin seattler,. G� 1900 fifth avenue seattle, washington 98101 206.728.1000 fax 206.728.2259 s,.. westin.com /seattle '�•wM ,e Py guest travel agent /charge to mom 2054 James Brainard 199.00 rate no. pers. 1 1 Civic Sq. folio 802602 EX -A Carmel, IN 46032 page 2 arrive 01- OCT -09 18:14 depart 04- OCT -09 UCI30A payment da e �n� t w refere e, rdesori P ion c x mrem v For your convenience, we have prepared this zero balance folio indicating a $0 balance on your account. Please be advised that any charges not reflected on this folio will be charged to the credit card on file with the hotel. While this folio reflects a $0 balance, your credit card may not be charged until after your departure. You are ultimately responsible for paying all of your folio charges in full. EXPENSE REPORT SUMMARY Date Room /Tax Food /Bev Telephone Other Total Payment 01- OCT -09 230.04 0.00 0.00 0.00 230.04 0.00 02- OCT -09 230.04 0.00 4.38 0.00 234.42 0.00 03- OCT -09 230.04 0.00 8.76 0.00 238.80 0.00 Total 690.12 0.00 13.14 0.00 703.26 0.00 For billing inquiries, please e -mail guestbilling.seattle @westin.com or call 206.727.5815. We look forward to welcoming you back soon! 1 agree to remain personally liable for the payment of this account if the corporation or other third party billed fails to pay part or all of these charges. signature As a Starwood Preferred Guest, you could have earned 1218 Starpoints for this visit. Please provide your member number or enroll today. James Brainard FOLIO 802602 01- OCT -09 EST1N HOTELS RESORTS Itinerary 130522561093 1/6/10 10:23 AM Print this pane Back to itinerary pane Washington, DC (6) Expedia Booked items Although this itinerary doesn't qualify for ThankYou Points, you can still eam r Than!You C" 'r points if you add a hotel booking today or any time before you travel. 4.44 r.,.. Learn more about hour to eam points for future bookings. Flight: Indianapolis to Washington bac:kIola% Expede itinerary number: 130522561893 Main contact: James Brainard Amine ticket number(a): 0377728397095 E -rrai: brainardjc @aol.com US Airways confirmation code: CDZFP1 Hone phone: (317) 573 -9929 Work phone: (317) 571 -2401 Traveler and cost summary James Brainard Adult Aftd Freauent Fiver num ber(e► $281.99 Taxes B Fees $21.41 Total ( $303.40 Chanoe this flight Request seat changes Print a receipt View cancellation information Flight summary Please be sure to re- confirm your flight at least 24 hours prior to scheduled departure (72 hours prior for flights to Hawaii and international destinations). You may check your flight status and departure gate online, or contact the airline directly. Seat assignments, meal preferences, and special requests must be conflmied with the airline; we cannot guarantee that they will be honored. Free and special meals are not awillable on many flights. Traveling to Washington Note: Youf airport check -In is with l Airways- Fri 15- ,Jan -10 Indianapolis (ND) to Washington (DCA) 487 mi US Airways Depart 4:10 pm Arrive 5:50 pm 784 km) Flight: 3088 TerrrinaIC Duration: 1hr40rm Operated by: US AIRWAYS EC:PRISS- CHAUTAUQUA AIRLINES EconomyfCoach Class (13D), Errbraer BuB -145 Total distance: 487 rri (784 km) Total duration: 1hr 40rm Traveling to Indianapolis Note: Your airport check -in is w th US Airways Fri 22- ,Jar-10 Washington (DCA) to Indianapolis (N) 487 mi US Airways Depart 7:20 pm Arrive 9:09 pm (784 Ion) Flight: 3431 Temlblal C Duration: 1hr49rm Operated by FAIRWAYS EXPRESS- REPUBLIC AIRLINES EconomylCoach Class (11C EMBRAER 170 Total distance: 487 in (784 km) Total duration: ihr 49rm d l o I Irfi fees a l a c heck n Fees maybe charged bysirlines For services such as preferred seat selection and baggage handling. Please no that fees are determined bythe airline you check in with and may change al anytime. See fees. http: //www.egredla. awn pub agentA nciso=open&RId= 305225610&vwtp =4 Page I of 2 ova Deers IJ;Im Ie17 AN Welcome, Elizabeth Sun in I S'cn a E xpedio' m eraries I IW Account I Oustoner subpart 1 Feedeock q, Sean, 619645 V Home Vacation Packages Hotels Care Flights I J Quineir "Jte9MNas DEALS OFFERS Maps Business Travel Rewards Total price for this trip:` Summar $232.30- r-" iTicket (Roundly cougars pm w What's aeoona 1- 800 -434 -2370 I1 hdienepois to Same great rates SEA Seattle Orly nano coupon nay he used per purchase. You're not signed h to- an account. To use a saved maiden, or to arms e coupon to your account, please sign in. pier erderL advks. a Leave: Tim 1 &Feb arp tn :41 r Return: Tua 23 -Fah 1 here a coupon. -Enter redtisn code_- ,r� I dart have a coupon. E l l 1 a 5333.31 eApPlY and reprice Tables es 8 Fees 939.31 Total 3732.30 r BOOK NOW 1 e Your Hight could cos l 1132 Instead of 0232! Get up to 5100 oft when you're approved. "I'' AND :RELA aj See details> &NMErped/a, Cuetemar Support c kang orcavco Q FmquanttrAs 1 Review the flight details on vrivally-Bfl n nS i asdoIFA Traveling to Seattle ..eee gil 5' Tue 16- Feb -10 Q Indianapolis (N3) to Chicago (olD) 169 nil American Airlines Depart 10:20 am Anne 10:25 am (272 ken) Flight: 3915 Teraina! 3 Duration, 1hr 5rrn Operated by: AMERICAN EAGLE COMMUTER SHRV ICEAME ICAN EAGLE ExonomylCoach Clays, C0umdian %gnna Jet 700 Chicago (CPo)) to Seattle (SEA) 1,723 mi American Airlines Depart 11:05 am Arrive 1:30 pm (2,773 km) Flight: 415 Trarenal 3 Drralkst Orr 25nn Economy :Caech Class, Boeing 737 -800 Taal diyMem 1,892 re (3,045 Ian) Total duration: 51,r 30rm (811r 1,00 wish connections) Traveling to Indianapolis `vim' Tue 23- Feb-10 Seattle (SEA) to Memphis (hap 1,866 mi Northwest Depart 1:15 am Arrive 7:21 800 (3,003 ill Flight: 2450 Duratpn: 41s Inn Economy/Coach Class, Feed Fm Rrrchase, Ai us A320 Memphis mine to Indianapolis (NJ) 382 mi Northwest Depart 8:45 am Aare 11:19 am lets long Flight 3926 Duration: 1h 34nn Operated by: NORTHWEST AriLIV( Economy /Coach Cony s, CArtreai R1 Total distance: 2,248 ni (3,618 Ian) Total duration: 511r 4000 (711r 4rm w htl connections) Tip: Flight terminals may change. Please confirm the terminal with the aidine before leaving for the airport. j3lAddltlonal airline fg,6aR10y99ply el choeisin Fees maybe charged byaldines for seri4ces such es preferred seat selection and baggage handling. Please note that fees are determined hythe a Wine you dteek In with and may Change 01 anytime. Sea foes. +`pis Save Even Vlore —Add a Hotel er padla recommended hotels Hilton Seaflle Quality Inn Sea Hilton Bellevue Airport Tac Airport t.O*0O 9 Conference... n 4 Bellevue itr{red15 SeeTa6 r bfericlati SeaTac More htp IT Wo hro Fight 7 nights Hotel Flight 7 rights Hotel Flgra 7 nights Hazel Booked separately: 31257 Trip Savings: 059 CO Total Rice: 91108 Total Rica: 9719 Total Rica: 31513 $1198 0719 51533 Includes: Flight It Nadi, includes. Flight +Natal, inclusive: Flight Now, al Tables a Farm 10.60 6 Fa. Taigas 6 Foes Ul Add this hotel to roar Irip (ID Add this ho1e1 to your trip ilia Add this betel to veer trip Add a hotel to your flight now See more hotels to cam ThankYOu'' Points and get great rewards! Your bestpnla, guaranteed! hapJMuudeseeteiconfy /seet.dth.r. .1x94597295 1 Page 1 uf 2 Page l of l LAcel,T k' ac, :(t Transaction Date: 09/01/2009 Tue Transaction Description: SOUTHWEST AIRLINES DALLAS TX SOUTHWEST AIRLINES From. To: Carrier: Class: INDIANAPOLIS IN DENVER no WN N OAKLAND CA WN N Ticket Number: 52621515937833 Date of Departure: 09/28 Passenger Name: BRAINARD /JAMES Document Type: PASSENGER TICKET Cardmember Name: 5 C BRAINARD Amount S: 150.20 Doing Business As: SOUTHWEST AIRLINES Merchant Address: PO BOX 36611 DALLAS TX DALLAS 75235 UNITED STATES I Reference Number: 320092450044714360 Category: Travel Airline https:// online.americanexpress.corn /myca /estmt/us /docs /print doc.html 1/6/2010 ('‘)/71±- S Marsh' 1Z9157145351 1.4110 9 AM �tp Welcome, Pazaheth Snmrn 1Sort nut a EJYxpel c. t y 3ineravts !My Accourn I Cosmmx Srmaon 1 Feedback WiYC �J {J 'EEgt Search Expedie d4 Hone Vacation Packages Hotels Cara Rights CWsm Activities DEALS& OFFERS Maps Business Travel Rewards IM Itinerante Seattle, WA (Chards anon) BOOKED ITEMS cosi Status Options Trip hlnerery 1 Trip maps end metes hItht 0gland seMtla 55880 Confirmed TRIP TOOLS Print version Booked items l ip Genell Itinerary 7. -'V 4C..7 CD Repeal e n u g itinerary Although this itinera dY quatify for ThankY Points, you can still earn eplaC ng Cu y 6U Than %Yougg* Sa' sori M extraordinary., Galata itinerary points U you add a hotel hooking today or any time before you travel- .....e,..e. resin am NEW wcvid OentrQsguid_l eil kb= and cetaceans Learn more about haw to earn points fob future bookings. Q save as appointment ary yp7 Da,llnatfon tnfa Flight: Oa kia.nd to Seattle Analo100 t A, �,ly" to Seattle Guide 9 If you need a pdrtted receipt for business purposes click here. hk ar Espsdis 9hnetery carter :129187449354 Main contact Jamn&ab>md 4• t rave lef$ customer support AKA. ac 027770 )13320 Ertel: eremardjc�aotcom A 9hhtxa FAOa Alaska Abunes mrdirretion code: PTKYBD Home phone: (317) 573 -9929 x {rat,1'N.. ay Work phone: 13171577 Lisa the [tummy -2301 a p .n g X,99121399-nulform I 7 r,aa�` Traveler and cost Summary �,,r�` ...tames Brainard Adult 54000 7 Taxes 8 Fees 510.80 4 4° Print a recast Total (American Express) 559.60 '11 g r g r P b Flight summary i rlu ra`oni:rp04S Please be sure to re- confirm your tight at least 24 hours prior to scheduled departure (72 hours prior for q flights to Hawaii and international destinations). You may check your flight status and departure gate '':n online, or contact 1,13eAd10s directly- Seat assignments, meal preferences, and special requests must be confirmed with the airline; we cannot guarantee that they will be honored. Free and special meals are not available on many flights. 5' Thu 1- Oct-09 .F TlO Oakland (O(OAK) to Seattle (SEA) 672 mi 047/ Depart 3:20 pm Anise 5111 pm (1.081 ern) Flight: 345 h"` ado Ter m ei 1 Duration. its 53rm Economy/Coach Class (11E), Boone 737 -700 Total distance' 612m krtp Total derision: ter 5lrmwl;:i EmAddltional airline fees may apply at check -1n 1 '„�h. r Y z Fees maybe charged twain Ines for serJces such es preferred seat selection end baggage handling. Plea ,e nate thatfees see determined by the ai dine you check in with end may change at any4me. .y-q d 7 1 M 1 by Airline rules 81 regulations ia� Ticket changes may incur penalties and(or increased fares. tickets are nontransferable and name changes are not allowed. Please read Important information regarding airline IiaMlity limitations. prices do not include baggage fees or tither fees charged directly by the airline. Other penalties may apply. See an overview of all the odes and restrictions applicable for this tare. View the complete penalty rtes for changes and canaellatlons associated with this fare. Elide l(ahtfUles Customer Support Itinerary number. 129167446354 (rya] hang questions about you reservation, fill out ou ithergeLassestamajerm. Well respond within 24 hours: For immediate assistance call Expedia at 1- 800- E)PEDIA (1$00 397 -3342) or 1 -404.728- E787 and hart the itinerary number reedy. Expedia IntoemsIiorc about Ereedle I add your holm 1 pram room I Investor r&•1100s 1 Erpedla'armee um I updates privacy policy 1 about ow ads I become an affiliate 1 advert Erpedha Links home 1 risers 1 hotels 1 raa 1 cruises 1 earn Memnon Points 1 Elite Plus 1 Egenda I cite m60 Expedia, Inc, is not repro+dbie for content on external Web ekes 1:12p10 Erpedie, Inc. All linnet marred. Photon: Oats Image', Codas heel .,....relenassepehfessia.dphpm -1 9s9x 1 of 9 Itinerary 129104030714 1/6/10 6:53 AM Print this pane 0 Back to itinerary page Indianapolis, IN Expedia Booked items Although this itinerary doesn't qualify for ThankYou Points, you can still earn 45 ThankYou9 "e points if you add a hotel booking today or any time before you travel. Pennant, tent ever Leam more about how to earn paints for future bookings. Flight: Seattle to Indianapolis back to too Expedia itinerary number: 129104090714 Main contact: James Brainard Airline ticket number(s): 0017700328095 E-mai: brainardjc @aot.com American Airlines confirmation code: PPGSRS Home phone: (317) 573 -9929 Work phone: (317) 571 -2401 Traveler and cost summary James Brainard Adult American Airlines #ue31074 $104.00 Taxes 8 Fees $21.20 Total ( $125.20 Change this flight Print a receipt View cancellation information Flight summary Please be sure to ro- confirm your flight at least 24 hours prior to scheduled departure (72 hours prior for flights to Hawaii and international destinations). You may check your flight status and departure gate online, or contact the airline directly. Seat assignments, meal preferences, and special requests must be confirmed with the airline; we cannot guarantee that they will be honored. Free and special meals are not available on many flights. Traveling to Indianapolis Note:Your airport check -In is with ALASKA AIriu ES. Sun 4 -Qct -09 Seattle (SEA) to Chicago (ORD) 1,723 mi American Amines Depart 8:40 am Arrive 2:35 pm (2,773 ken) Flight: 6815 Terninal 3 Duration: 3hr 55nn Operated by: ALASKA AIRLINES Economy /Coach Class (27C Food For Purchase, Boeing 737 Chicago (oRD) to Indianapolis (ND) 169 mi American Airlines Depart 325 pm Arrive 5:20 pm (272 km) Flight: 3989 Terminal 3 Duration: Ohr 55rm Operated by: AMERICAN EAGLE COMMUTER SERVICE/AMERICAN EAGLE Economy /Coach Class (12C Food For Purchase, Canadnn Regional Jet 700 Total distance: 1,892 m (3,045 km) Total duration: 4hr 50rm (5hr 4Orm w ith connections) Additional airline fees may apply at check In Fees maybe charged by airlines for services such as preferred seat selection and baggage handling. Please note that fees are determined by the airline you check in with and may change at anytime. See fees. Airline rules regulations Ticket changes may incur penalties and /or increased fares. Tickets are nontransferable and name changes are not allowed. http:// www. expedla. mm/ publagent. d? gscr =open&itid Page 1 of 2 Page 1 of 2 Chastain, Jenny A From: Jim Brainard [Brainardjc @aol.com] Sent: Thursday, January 14, 2010 2:05 PM To: Chastain, Jenny A Subject: Fwd: Ticketless Confirmation BRAINARD /JAMES NVR8UD Found it! Sent from my iPhone Begin forwarded message: From: "Southwest Airlines" SouthwestAirlines @luv.southwest.cotn> Date: September 1, 2009 7:58:42 PM EDT To: BRAINARDJC @AOL.COM Subject: Ticketless Confirmation BRAINARD /JAMES NVR8UD Reply -To: "Southwest Airlines" <no- reply @luv.southwest.com> itj Save LIp Q' 'O% Ott Ta redeem„ nter 11 10 to e the SOUTHWEST.C©NT plus double credit Qn Avis rentalss corvtto ttelet Receipt and Itinerary as of 09101/09 6:58 PM Confirmation Number Sit NVR8UD Where like Confirmation Date: 09/01/09 Received: WN /JAMES BRAINARD BY ICBM Be prepared when you get there! Consult Travel Guide for relevant tips from real travelers. Passenger Information Passenger Name Account Number Ticket# Expiration BRA1NARD /JAMES 00001037393534 5262151593783 09/01/10 1 All travel involving funds from this Confirmation Number must be completed by the expiration date. Itinerary Date Flight Routing Details Mon Sep 28 3885 Depart INDIANAPOLIS IN (IND) at 4:50 PM Arrive in DENVER CO (DEN) at 5:35 PM 0477 Change planes in DENVER CO (DEN) departing at 6:25 PM Arrive in OAKLAND CA (OAK) at 8:00 PM Cost and Payment Summary Air $120.00 Tax $16.20 1/14/2010 Page 2 of 2 PFC Fee $9.00 Security Fee $5.00 Total Payment: 150.20 Current payment(s) 09/01/09 $150.20 Fare Rule(s) All travel involving funds from this Confirmation Number must be completed by the expiration date. Any change to this itinerary may result in a fare increase. Fare Calculation: IND WN XIDEN WN OAK120.00N14NTNR 120.00 END ZPINDDEN XFIND4.5DEN4.5 AY5.00 $IND2.50 DEN2.50 Important Checkin Requirement Passengers who do not obtain a boarding pass and are not present and available for boarding in the departure gate area at least ten minutes prior to scheduled departure time may have their reserved space cancelled and will not be eligible for denied boarding compensation. Southwest Airlines Co. Notice of Incorporated Terms Air transportation by Southwest Airlines is subject to Southwest Airlines' Passenger Contract of Carriage, the terms of which are incorporated by reference. Notice of Incorporated Terms Additional Information for Travelers Online Checkin 1 Free Baggage Allowance 1 Checkin Requirements I Print Security Document Inflight Service I Travel Tips 1 Refund Information I Privacy Policy 1 Southwest Airlines Destinations We can notify you of flight departure or arrival status via text messages on your cell phone, pager, personal digital assistant (PDA), or e-mail account. Or, use our automated phone service by calling 1- 888 -SWA -TRIP. 1/14/2010 =d by State Board of Accounts City Form No. 201 (Rev. 1995) 124 ACCOUNTS PAYABLE VOUCHER 1/11/10 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 Mayor Jim Brainard Purchase Order No. 12662 Royce Ct. Terms Carmel IN 46033 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 10/4/09 802602 Hotel accommodations for Mayor Brainard Fall USCM $703.26 Leadership Meeting 10/1/09- 10/4/09 1/5/10 Stmt Airfare roundtrip Indianapolis to Seattle, WA $232.30 1/6/10 Stmt Airfare roundtrip Indianapolis to Washington. DC $303.40 (USCM Winter meeting 1/20 22/10) Stmt Hotel one night guarantee $221.00 Stmt Conference registration $600.00 Total $2,060.26 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 4CHER NO WARRANT NO. 1%11/10 ALLOWED 20 Mayor Jim Brainard IN SUM OF 12662 Rouye Ct. Carmel IN 46033 $2,060.26 ON ACCOUNT OF APPROPRIATION FOR 1160 Mayor 4343003 4343002 Travel Lodging and External Training Travel Board Members =Pre INVOICE NO. ACCT# /TITLE AMOUNT I hereby certify that the attached invoice(s), or 802602 4343003 $703.26 bill(s) is (are) true and correct and that the Stmt 4343003 $232.30 materials or services itemized thereon for Stmt 4343003 $303.40 which charge is made were ordered and Stmt 4343003 $221.00 received except Stmt 4343002 $600.00 I -I/ 20 w 1 Sign ure Title Cost distribution ledger classification if claim paid motor vehicle highway fund