181495 01/20/2010 CITY OF CARMEL, INDIANA VENDOR: 362339 Page 1 of 1
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t ONE CIVIC SQUARE CITIZENS MANAGEMENT INC
t
/,'.17;k:, )a CARMEL, INDIANA 46032 Po BOX 620 CHECK AMOUNT: $26,785.43
1ioi HOWELL MI 48844 -0620 CHECK NUMBER: 181495
CHECK DATE: 1/2012010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347000 26,785.43 WORKMEN'S COMPENSATIO
01/15/2010 13:41 FAX 517 548 9246 CITIZENS MGMT INC 1}002
4Citizen.s
Management Mc-
A nrmpanyel Hanever insurark¢ Group Citizens Management Inc. PO Box 620, Howell, MI 48844 -0620 Loss Fund Invoice
TO: MS. SHELLY M. LINGELBAUGH
CITY OF CARMEL
ONE CIVIC SQUARE
CARMEL, IN 46032
DATE: 01/15/2010
LOSS FUND INVOICE
REFERENCE SWC00003I85
INITIAL DEPOSIT $25,000.00
01/15/2010 BALANCE $1,785.43
1 AMOUNT DUE $26,785.431
REFERENCE SWC00003815
INITIAL DEPOSIT $25,000.00
01/15/2010 BALANCE $1,785.43
AMOUNT DUE $26,785.431
VOUCHER NO. WARRANT NO.
ALLOWED 20
Citizens Management Inc.
IN SUM OF
PO Box 620
Howell, MI 48844 -0620
$26,785.43
ON ACCOUNT OF APPROPRIATION FOR
Carmel Administration
PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1205 43- 470.00 $26,785.43 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
Friday, January 15, 2010
Director, A-+Risttion
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))
01/15/10 Loss Fund Invoice $26,785.43
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
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Clerk- Treasurer