HomeMy WebLinkAbout181936 02/03/2010 7 --11,..„, CITY OF CARMEL, INDIANA VENDOR: 00351325 Page 1 of 1
(.j i ONE CIVIC SQUARE DAVID HUFFMAN CHECK AMOUNT: $5,000.00
CARMEL, INDIANA 46032 C/O STREET DEPARTMENT
0 C/O STREET DEPARTMEN CHECK NUMBER: 181936
CHECK DATE: 2/3 /2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 5,000.00 ADOPTION ASSISTANCE
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City of Carmel r
Adoption Assistance Claim Form
SEE REVERSE SIDE FOR INFORMATION AND INSTRUCTIONS
Employee Iinfortritiori
6mpioyee Nathe Last): 1
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Social Security Number: Work Phone: 3 A(DC)
Employee ID Number: L73 Home Phone: z/r7 5 5-
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Child's Name: / / Date of Birth:
SSN (if known): Final Adoption Date:
Attach copy of adoption decree if adoption has been finalized_
Date: Paid To: Services Rendered: Amount:
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Attach original itemized receipts in U.S. dollars for all expenses listed above, No reimbursement will be made without appropriate documentation.
Attach separate sheet of paper for additional expenses.
hereby request reimbursement for the adoption expenses listed above. By signing below, I certify that:
)1 Check appropriate box: The child identified above has been placed in my home pursuant to adoption or
The adoption of the child identified above has been finalized and
2 To the best of my knowledge, each expense listed above is a qualified adoption expense under the City of
Carmel Adoption Assistance Program; and
3 All statements and documentation relating to this claim are true and complete.
understand that incomplete or inaccurate information may adversely affect my eligibility for benefits through the
,doption Assistance Program.
.mployee Signature: Date:
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
David W. Huffman Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
01/26/10 Adoption Assistance $5.000.00
Total $5,000.00
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 01126/10 WARRANT NO.
ALLOWED 20
r David W. Huffman IN SUM OF
$5,000 00
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Escrow
Board Members
PO# r INVOICE NO. ACCT #/TITLE AMOUNT hereby certify invoice( s), DEPT. I hereb certi that the attached invoices or
bill(s) is (are) true and correct and that the
301 $5,000.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund