181785 02/03/2010 CITY OF CARMEL, INDIANA VENDOR: 356246 Page 1 of 1
r` ONE CIVIC SQUARE AETNA CHECK AMOUNT: $368.86
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CARMEL, INDIANA 46032 PO BOX 981107
o CHECK NUMBER: 181785
CHECK DATE: 2/3/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 368.86 OTHER EXPENSES
Date: 01/21/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
Bill To: NICHOLAS N POLETIKA ICD -9: 78652 71941 3688 E8131
13653 WOOD MILL
CARMEL, IN 46032-
From: 111TH PENNSYLVANIA
To: METHODIST HOSPITAL
1 AETNA US HEALTHCARE /981106
Patient: CAROL POLETIKA 000248463
13653 WOOD MILL Insurance
CARMEL, IN 46032- 2
Patient No: 200901895
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$433.95 $499.04 65.09
CPT
Date Description Charges Credits
07/26/2009 ADVANCED LI=E SUPP 1 -EMER A0427 $375.00
07/26/2009 MILEAGE A0425 $58.95
11/13/2009 COMMERCIAL INSURANCE PAYMENT $368.86
01/08/2010 PAYMENT $65.09
01/20/2010 COMMERCIAL INSURANCE PAYMENT $933.95
01/21/2010 REFUND 368.86
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/21/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
Bill To NICHOLAS N POLETIKA ICD -9: 78652 71941 3688 E8131
13653 WOOD MILL
CARMEL, IN 46032
From: 111TH &s PENNSYLVANIA
To: METHODIST HOSPITAL
1 AETNA US HEALTHCARE /981106
Patient: CAROL POLETIKA 000248463
13653 WOOD MILL Insurance
CARMEL, IN 46032- 2
Patient No: 200901895
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$433.95 $867.90 433.95
CPT
Date Description Charges Credits
07/26/2009 ADVANCED LIFE SUPP 1 -EMCR A0427 $375.00
07/26/2009 MILEAGE A0425 $58.95
11/13/2009 COMMERCIAL INSURANCE PAYMENT $368.86
01/08/2010 PAYMENT 65 09
01/20/2010 COMMERCIAL INSURANCE PAYMENT $433.95
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/21/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal1D# 356000972
AC; a te, _u e g, S7 w °s
Bill To: NICHOLAS N POLETIKA ICD -9: 78652 71941 3688 E8131
13653 WOOD MILL
CARMEL, IN 46032- From: 111TH PENNSYLVANIA
To: METHODIST HOSPITAL
AETNA US HEALTHCARE /981106
Patient: CAROL POLETIKA 000248463
13653 WOOD MILL Insurance
CARMEL, IN 46032- 2
Patient No: 200901895
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT 15 YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$433.95 $499. 65.09
CPT
Date Description Charges Credits
07/26/2009 ADVANCED LIFE SUPP 1-FMER A0427 $375.00
07/26/2009 MILEAGE A0425 $58.95
11/13/2009 COMMERCIAL INSURANCE PAYMENT 0368.86
01/08/2010 PAYMENT $65.09
01/20/2010 COMMERCIAL INSURANCE PAYMENT $433.95
01/21/2010 REFUND 368.86
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
025241 J1K2P1B 072538
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P.O. BOX 981107 EXPLA BE
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Aetna
Please Retain for Future Reference
CITY OF CARMEL FIRE DEPT. 1 PIN: 000574510(
Check No: 09817/07366493f
Page 2 of 3 (1)
Date'Printed: 11/03/2009
CITY OF CARMEL FIRE DEPT. Tax identification Number XXXXXXXX0972
2 CIVIC SQ Check. Number: 0981
CARMEL IN 46032 -2584 Check Amount: $430.78
1 1111111I1J11111111111I1ItJi11IiIl1 „Ittt.111C1111111 1111!
RECEIVED E )V 3 ZQO9
Notes:
Update your address, telephone number, email address and /or N PI information by visiting www.aetna.com /provweb/ or
www.aetnadental.com and select Update Personal Information.
Patient Name: CHRISTA P ISAACS (Serf)
Claim ID: E7JKJVT9N00 Recd: 10/21109 Member ID: W160294812 Patient Account: 200902112
Member: CHRISTA P ISAACS DIAG: 78909 6959 E8131
Group Name: EQUIFAX INC. Group Number: 800071 -23 -001 FA P1+
Product: Aetna Choice® POS 1I Network ID: 00000
Aetna Life Insurance Company
SERVICE PL SERVICE .j' NUM ,'SUBMITTED ALLOWABLE tCOPAY NOT SEE;::; DEDUCTIBLE CO PATIENT ii PAYABLE.::;
DATES '!'?CODE SVCS CHARGES, AMOUNT AMOUNT PAYABLE? REMARKS INSURANCE2RESP AMOUNT
08/20109 41 A0429SH 1.0 325.00 300.00 5 00 305:00 20.00
08/20/09 41 A0425SH 8,0 52.40 1048 10.48 41.92 TOTALS 377.40 300.00 15.413 315:48 61.92
MMIMINIMMIN
'ISSUED AMT: $61.92
For Questions Regarding This Claim O. BOX 14079 LEXINGTON KY 40512 -4079 Total:Patient Responsibility: $315:48
CALL (888) 632-3862 FOR ASSISTANCE
Clalrri :Payment $61 92
Note: All .Inquiries should reference the ID number above for. prompt response
Patient Name: CAROL M POLETIKA (Spouse)
Claim ID: EKAAJ2KQ500 Recd: 10/26/09 Member ID: W142936218 Patient Account: 200901895
Member: NICHOLAS N POLETIKA DIAG: 78652 71941 3688
Group Name: THE DOW CHEMICAL COMPANY Group Number: 783135 -35 -001 AS D7 <D >0
Product: Aexcel0 Plus Open Choice® Network ID: 00000
Aetna Life Insurance Company
'SERVICE )PL SERVICE ..NUM SUBMITTED s ALLOWABLE :'.COPAY NOT .:BEE!.; „DEDUCTIBLE„ CO'.' PATIENT PAYABLE,
DATES ;:CODE SVCS CHARGES AMOUNT AMOUNT PAYABLE REMARKS INSURANCE RESP AMOUNT
07126/09 41 A0427SH 1.0 375.00 56 25 56.25 318':75
07126/09 41 A0425SH 9 0 58.95 8 84 8.80. 50:14
TOTALS 433.95
65.09 368.86
ISSUED :AM '$368.86
For Queshons,;Regarding This Claim
P. 0. BOX 981109 EL' PASO TX 79998 1109 Total.! Patient'Responsibillty $65.09
'CALL (888) 632 -.3862: FOR.ASSISTANCE Claim Payment .$368:86
Note All Inquiries should reference the ID numberabove for prompt response:.
P.O. BOX 981107 r h n�
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I, Aetna USAp.SO,TX 79998.1107 L.H11V1 �.F �/IYt
6Z5241 J1K2PJt. 672537 (2) Please Retain for Future Reference
CITY OF CARMEL FIRE DEPT. PIN: 0005745100
Page 1 of 3 (1
CITY OF CARMEL FIRE DEPT.
2 CIVIC SO
CARMEL IN 46032 -2584
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CLAIM NO 14-2357-816 POLY NO 0509-074-14A LOSS DATE 07-26-2009 PAYMENT NO 1 18 407103 :,.I
Coverage Des cr ipt ion Amount COL Pay Cti DATE 01-13-2010
MEDICAL PAYMENT $433.95 600 2 AMOUNT $433.95
TIN 14-356000972
ENTERED BY POL1N, SHERRI
AUTHOR I ZED BY POLIN, SHERFI1
PHONE (866) 648-0715
REMARKS 7/26/2009 7 /ZLIC ei
1 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 407103 J
WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56-1544/441
COLUMBUS, OH
MPC INDIANA 18-501 L025
01-13-2010
DATE MM Do y yy y
CLAIM NO 14-2357-816 INSURED POLETIKA, NICHOLAS
LOSS DATE 07-26-2009 ON BEHALF OF CAROL POLETIKA
***************EXACTLY FOUR HUNDRED THIRTY-THREE AND 95/100, $*******433 .95
Pay to the
Order of CARMEL FIRE DEPARTMENT
2 CIVIC SQ
CARMEL IN 46032-2584
1 APPROVED BY
E s Ell 2 C) l-li l'°
17 /1" l e loci
CLAIM NO 14-2357-816 POLICY NO 0509-074 LOSS DATE 07-26-2009 PAYMENT NO 1 18 407103 J
Coverage Description Amount COL Pay Cd DATE 01-13-2010
MEDICAL PAYMENT S433.95 600 2 AMOUNT $433.95
TIN 14-356000972
7 7...: I.:
AUTHOR I ZED BY POLIN, SHERRI
PHONE (866) 648-0715
REMARKS 7/26/2009
't
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 '4'07103 J
WEST LAFAYETTE IN JPMORGAN' CHASE BANK NA 56-'1544/441
COLUMBUS ,OH s
MPC INDIANA 15 501 L025
DATE Mr1 00 YYY
t -1 1 CLAIM NO 14-2357-816 s INSURED POLETIKA, NICHOLAS
LOSS DATE 07-26-2009 ON BEHALF OF CAROL POLETIKA
ii
c.)
FOUR HUNDRED THIRTY-THREE AND 95/100 DOLLARS $*******4 3 3 95 01
Pay to the o
q Order of CARMEL FIRE DEPARTMENT 1:1
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2 CIVIC SQ 2
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CARMEL IN 46032-2584
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AUTHOR I ZED SIGNATURE 6i>9
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11.16 I Trio? LC) 1 1 m ':DLit 5 till 31: 1 26 290 2 3 30
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.
��f� Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
-6241 ursei eec r nVerpn e)
r o j J o /e i Alm
Total,3 70Y,
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
e j-) IN SUM OF &,1 �4�>
,r) gY /0 �7
i s� 7 99q?
s2td.
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT /TITLE AMOUNT hereby certify invoice( s), DEPT. I hereb certif that the attached invoices 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
rEB ,w1 2010
1A 20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
CITY OF CARMEL, INDIANA VENDOR: 363860 Page 1 of 1
ONE CIVIC SQUARE ALOFT BOLINGBROOK
Ii CHECK AMOUNT: $1,378.08
1 CARMEL, INDIANA 46032 500 JANES AVE
o BOLINGBROOK IL 60440 CHECK NUMBER: 181789
CHECK DATE: 2/3/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1115 4343002 1,378.08 TRAVEL PER DIEMS
Starwood Hotels Resorts Page 1 of 2
Thank you for your reservation! We look forward to seeing you.
Name: MARCIA WALTON
Confirmation Number: 764558829
Hotel Room Information
Aloft Bolingbrook Check In Check Out
500 Janes Avenue 02/21/2010 3:00 PM 02/25/2010 12:00 PM
Bolingbrook, Illinois 60440 United States
Phone: (630) 410 -6367 Fax: (630) 410 -6368 3 Rooms, 1 Adult per room. 1 King, Non smoking room
Room 1: MARCIA WALTON
Room 2: JANIGE TYLER
Room 3: WILLIAM MCGEE
Room Features: Aloft Non smoking -285 Sq Ft Free High-
speed Internet 42 Inch Flat Screen Lcd Tv Oversized
Shower Rest And Relaxation Bed
Rate Information
Rate Description: Reserve Relax Advance Purchase Rate Is Fully Prepaid, Non Changeable, Non Refundable.
SET or Corporate Account Number:
Average est. room total per night Estimated total for your stay
Room rate: USD 99.00 3 rooms) for 4 night(s): USD 1,378.08
Taxes: USD 15.84
Estimated total USD 114.84
*The displayed totals are estimates only and do not include any additional charges that may be incurred at the hotel. The actual
total will be caicutated by the hotel in its local currency, based on the local taxes and currency exchange rate (if applicable) in
effect at the time charging occurs.
Personai and Credit Card Information
Name: MARCIA WALTON
Address: 7434 N CARROLL RD
INDIANAPOLIS IN 46236, US
Telephone number: 3174409630
Email: mwalton@carrnel.in.gov
Credit Card Number: xxxx xxxx -xxxx -2009
View our Privacy Statement
Starwood Preferred Guest Information
SPG Number
Starchoice Number:
Optional Information
Hotel Arrival Information: 04:00 PM
Special Requests: Please note that special requests cannot be guaranteed until check -in, but
we will do our best to accommodate you.
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Starwood Hotels Resorts Page 2 of 2
Terms and Conditions
Cancellation Policy: The time for canceling without penalty has passed. If you
cancel, the forfeiture amount will be 100.00 percent. There
may be additional applicable charges and taxes,
Rate Plan Description: Reserve Relax Advance Purchase Rate Is Fully Prepaid,
Non Changeable, Non Refundable.
GTO /Deposit Policy: USD 1188.00 deposit is due on 01/26/2010 and wit be
charged to the credit card provided.
For reservations guaranteed with a form of payment at time
of booking, rooms are held until hotel check -out time the day
following arrival. For reservations not guaranteed with a foam
of payment at time of booking, rooms are held until set
cancellation time per the rules of the reservation, In the event
more guests arrive than can be accommodated due to hotel
overbooking or an unforeseen circumstance, and hotel is
unable to hold rooms consistent with this room hold policy,
hotel will attempt to accommodate guests, at its expense, at
a comparable hotel in the area for the oversold night(s), and
will pay for transportation to that hotel.
Currency Conversion
For non -US hotels, rates confirmed in USD may be converted to local currency by the hotel at your time of stay, based on the
exchange rate used by the hotel and are subject to exchange rate fluctuations. Credit card charges are subject to additional currency
conversions by banks or credit card companies, which are not within the hotel's control and may Impact the amount charged to your
credit card. Please contact the hotel if you have any questions.
Passport Requirements
New passport restrictions for travel between the United States and Canada, Mexico, Bermuda, and the Caribbean region are now in
effect. More information is available from the U.S. Department of State here or check your country's travel and transit requirements
to /from the United States.
Early Departures
Many Starwood hotels have an early departure fee. When you check in, you will be asked to confirm your departure date. You may be
able to change your departure date without a penalty if your rate plan permits and if you do so at time of check -in. After reconfirming
your departure date, if you decide to leave earlier, you may be charged the early departure fee. Please contact the hotel if you have
any questions.
ID Requirements
For security purposes, you will be asked to provide a photo ID at check -in.
For Assistance
For Reservations, Starwood Preferred Guest® Assistance, Redemptions or Reservations call toll free 888 625- 498�E n e i1.S. or
Canada. Or you may contact one of our Worldwide Reservations Offices.
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INSTITUTE..
Fire Service Communications, 1 Edition
Date February 22-25, 2010
Location Romeovi lle Police Dept.
698 North Birch
Romeoville, IL 60446
Time 8 :00 a.m.' 5 :00 p.m.
Course 28140
Co-host agency Contact
Romeoville Police Dept. Kim Knutsen
(815) 693 -4980
Lodging Lodging
Country Inn Suites Comfort Inn
1265 Lakeview Drive 1235 Lakeview Drive
Romeoville, IL 60446 Romeoville, IL 60446
888 -201 -1746 877- 424 -6423
(630) 378 -1052 (630) 226 -1900
APCO Institute, Inc.
351 N. Williamson Blvd.
Daytona Beach, FL 32114-1112
888 -272 -6911 or 386- 322 -2500
FAX: 386 -322 -9766
www. a p co i n stitu te. o rg
VOUCHER NO. WARRANT NO.
ALLOWED 20
Aloft Bolingbrook
IN SUM OF
500 Janes Avenue
Bolingbrook, IL 60440
$1,378.08
ON ACCOUNT OF APPROPRIATION FOR
Carmel Clay Communications
PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1115 43- 430.02 $1,378.08 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
Tuesday, January 26, 2010
Director
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))
01/26/10 I 1 $1,378.08
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