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181159 01/13/2010 o. CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1 1.; ij ONE CIVIC SQUARE DON CLEVELAND 1 CHECK AMOUNT: $832.25 t CARMEL, INDIANA 46032 141 STONY CREEK OVERLOOK NOBLESVILLE IN 46060 CHECK NUMBER: 181159 CHECK DATE: 1/13/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4347500 832.25 INSURANCE Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland Jan -10 Donald: Medicare Part B $96.40 Amount due for January 2010 Humana Choice PPO 73.00 Total Don 169.40 Approved by Ron Carter Barbara: Anthem 809.72 Total Monthly 979.12 85% 832.25 Portion paid by City 15% 146.87 ANTHEM BCBS IN INDIVIDUAL INDI -MB 1 KY0303A645 001617 1351 Wm Howard Taft. I Cincinnati, OH 45206 -1775 em` An independent licensee of We Blue Cross aid Bloc Shield Assr =.Molt Anthem Bloc Cress ]31uc Shield is +hc 0adc narrc of 11c A 0hon hvsuranee Cmi,,anics, lac. ®Hegixlere l narks Illu.. Cra .sand ©lac Shield Assxiation. IDENTIFICATION #:018M62629 1211091V131.22920 WIND 161701 Due Date: 01 -01 -2010 IIIIIIlIIiiII11 ILlllilllllluIII Billing Date: 12 -10 -2009 #BWNCQXF Coverage Period From: 01-01-2010 Q #AI 1V 10000000000DS0 #INDI MB KY0303A645 Coverage Period Through: 01 -31- 2010 A Cleveland, Barbara L 141 Stony Creek Overlook 'Total Amount Due: $80').72 Noblesville, IN 46060 -5427 SEE REVERSE SIDE FOR BILLING DETAILS. Questions about your bill or interested in making your payment over the phone? For assistance, please call the Customer Service phone number listed on the back of your Identification Card. Choosing to mail in your payment? Please allow 7 to 10 days to ensure timely processing of your payment. Please list. your 9 -digit Identification Number on your check, include the Tower portion of this page and mail to the address specified. If you pay by check, Anthem Blue Cross and Blue Shield charges a "Non-Sufficient Funds" (NSF) fee of $20 for returned, unpaid checks. IMPORTANT NOTICE: If you have received a reminder notice from Anthem regarding a past due payment, this bill includes all amounts that you owe to keep your policy in force. To avoid any lapse in coverage, the Total Amount Due listed on this bill must be received by the Due Date. Anthem's issuance of this bill does not waive its contractual right to automatically terminate your coverage for failure to pay premiums in a timely manner. Payments recently mailed may not be reflected. DETACH AND RETURN THIS SECTION WITH YOUR PAYMENT DO NOT STAPLE MAKE CHECKS PAYABLE TO ANTHEM BLUE CROSS BLUE SHIELD Cleveland, Barbara L AND MAIL TO THE ADDRESS BELOW Subscriber II) From Date Through Date Due Date 018M62629 01/01/2010 01/31/2010 01/01 /2010 Amount Due Amount Paid $809.72 9 G 9 7Z Unit No. 002 INDI -MB1 X/" y/ &2 1 73 I.I 11 11,11.111.11.11.11.11,11 I,IIlII,1I1I11 II IIL I ANTHEM BCBS IN INDIVIDUAL PO Box 105674 Atlanta GA 30348 -5674 1 4001954140000018226262970101201000000809720020 Si necesita ayuda en espanol para entender este documento, puede solicitarla sin costo adicional, llamarulo al numero de servicio al cliente que aparece al dorso de su tarjeta de identi f cation o en el folleto de inscription. Invoice 062432394 PRIOR BILLING PERIOD COVERAGE FROM 12/01/2009 THRU 12/31/2009 Previous Total Due $809.72 Payment Received on 12101 /2009 ($809.72) Outstanding Balance as of 12- 10- 21109 $0.00 CURRENT PERIOD COVERAGE FROM 01 /01/20.10 THRU 01/31/2010 Plan 11. $809.72 Current Period Total $809 72 PLEASE PAY THIS AMOUNT $809.72 ibl3B11VD2/1 813_11_1ND_00001617_000062432394 Prescribed by State Boardiof Accounts 1 t t i t t City Form No. (Rev. 1995) I j �i ACCOUNTS PAYABLE; V CITY OF CARI\MEL f properly ndofs t u E e itemized must show: kind -_i_ k_ An invoice or bill to s ervice, where performed, dates service rendered by i 1 22 G whom, itates per day umber of, hours, rate per hour, number iof units price per unit, etc. i i i i i I i i Payee ,I,/ /7 C Purchase Order No. (Y( S�Ue.� �i--� /o--. Terms //'6 ,,sue,/l /2/ `16:GAG Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Oro( (0 ,J u,,r� 20/6 s 25.4 -z 5 e5 i 3 t .tea Total Y -45 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 VOA ,-/j y( .5 f�H C �IU /G�i{ IN SUM OF R5.Q_ ON ACCOUNT OF APPROPRIATION FOR '2/ 3r7 Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT hereby certify invoice(s), 1 hereb certi that the attached invoices or /C'(10 3 V 7 5 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 —ll 20/ MOM Sigg j: ture ®!rector of Aerations Cost distribution ledger classification if Title claim paid motor vehicle highway fund