181609 01/20/2010 CITY OF CARMEL, INDIANA VENDOR: 360618 Page 1 of 1
ONE CIVIC SQUARE STEPHANIE MARSHALL
3 o CHECK AMOUNT: $283.38
CARMEL, INDIANA 46032 578 TULIP POPPLUR CREST
o CARMEL IN 46033 CHECK NUMBER: 181609
CHECK DATE: 1/20/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4347500 120109 283.38 GENERAL INSURANCE
Coverage Tier
Period Premium I
BC8S HDHP /HSA Medical Plan Employee Family 12/01/2009 12/31/2009 310.68
Delta Dental Plan Employee Family 12/01/2009 12/31/2009 2271
IMININILMEEM
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MENEEMNION
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Comments Notes: Subtotal: S333.39
Amount Paid: S0.00
Total Due: $333.39
Return this Coupon and Your Payment to: Coverage for:
Medcom Richard Marshall, Jr, Due Date: 12/01/2009
P.O. Box 10269 Total Enclosed:
Jacksonville, FL 32247.0269 578 Tulip Poplar Crest
Carmel, IN 46033 Make Check Payable to:
Medcom
Clip Coupon Here and Return wlih Your Payment
www.hsabank.com
RICHARD C MARSHALL JR 107
578 TULIP POPLAR CREST
CARMEL, IN 46033
Y 13 1 0.a7=
Pay to the 0`
Order of 17749Cee;erisl______
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Coverage Tier Period Premium
BCBS HDHP /HSA Medical Plan Employee Family 12/01/2009 12.`31/2009 310.68
Delta Dental Plan Employee Family 12/01/2009 12/31/2009 22.71
Comments r Notes: Subtotal: $333.39
Amount Paid: S0.00
Total Due: $333.39
Return this Coupon and Your Payment to: Coverage for:
Medcom Richard Marshall, Jr. Due Date: 12101I2O0
P.O. Box 10269 Total Enclosed:
Jacksonville, FL 32247.0269 578 Tulip Poplar Crest
Carmel, IN 46033 Make Check Payable to:
Medcom
Clip Coupon Here and Return with Your Payment
•mvw.hsabank.corn
RICHARD C MARSHALL JR 107
578 TULIP POPLAR CREST 79- 794/759
CARMEL, IN 46033 /L
Pay to the
0 rcler of 117Cd(
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For Eligible Medical Expenses ;I,y
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If you hav any que concer
your account; please contact is.
as kus@hsabank corn
Para un representante en espanol, por favor Ilamar al 866 357 -6232
Richard C Marshall Jr
578 Tulip Poplar Crest I ACCOUNT NUMBER: 1 1 PREVIOUS BALANCE
Carmel, IN 46033 189011 506.28
V PAGE PE I 1‘ 'TOTAL CREDITS
1'{of 12101- -12/31 .:1. $2:
R EARNED. I pTAL DEBIT
$2 34 1 $333:39 li
r, _f ENDING B�ALANGE.
$7346:` :$3,175.23
Hsa �n
Credits .''Date .Balance
BALANCE LAST STATEMENT 11/30/2009 3,
PERCENTAGE YIELD EARNED FOR 31 DAYS IS 0.85% Total'Fnr This Total
;INTEREST EARNED DURING CYCLE PERIOD' 2.34 Period Year -to -Date
I.CURRENT tNTEREST RATE 0.84 °6 Total Overdraft Fees 3220 $3.00,:,
AVERAGE BALANCE FOR THIS STATEMENT CYCLE:" $3,258.93
i `Total Returned Item Fees $0:00 $0.00
Hsa„,
.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
5 .71
q/".,4 Purchase Order No.
CK G Terms
Date Due
Invoice Invoice Description Amount
Date Number (or n ote attached invoice(s) or bill(s))
12,( c� 02 120( G �c O� rM irns'o 2 3 _3
Total 2 3 3c.5
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
IN SUM OF
2 CSC
23 ..38
ON ACCOUNT OF APPROPRIATION FOR
9e2/ cl
Board Members
O# or INVOICE NO. ACCT #/TITLE AMOUNT I hereby y certify that the attached invoice(s), or
d2
/2.0( c 1 2 33 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
f3 20 /ct
41 4` u re
Di or of Operations
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund