182053 02/03/2010 CITY OF CARMEL, INDIANA VENDOR: 363863 Page 1 of 1
i. ONE CIVIC SQUARE CAROL POLETIKA
CARMEL, INDIANA 46032 13653 WOODMILL COURT
CHECK AMOUNT: $65.09
CARMEL IN 46032 CHECK NUMBER: 182053
CHECK DATE: 213/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 65.09 OTHER EXPENSES
Y
Date: 01/21/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ►D# 356000972
ACCOUNT HiSTORY
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
13653 WOOD MILL Insurance
CARMEL, IN 46032- 2
Patient No:
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 LIFE 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 $433.95
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 !D# 356000972
ACCOUNT .J..-.
Bill To: NICHOLAS N POLETIKA ICD 9: 78652 71941 3688 [8131
I
13653 WOOD MILL
CARMEL, IN 46032
From: 111TH PENNSYLVANIA
To: METHODIST HOSPITAL
AETNA US HEALTHCARE /981106
1
Patient: CAROL POLETIKA
13653 WOOD MILL Insurance
CARMEL, IN 46032- 2
Patient No:
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 $433.95 $0.00
CPT
Date Description Charges Credits
07/26/2009 ADVANCED LIFE 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 $433.95
01/21/2010 REFUND 368.86
01/21/2010 REFUND -65.09
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
f
i
V
NICHOLAS N. POLETIKA
CAROL M: POLETIKA W
1 45
3653 OODMELE_ -CT.
92i). 3GS3 CARMEL, IN 46032 c2 2 1D 20 7380/2740
r
1p.Yt ()IWO
Iio
order o ,T i 6 cx,
Z 7, d Dollars If1
For'
cce
GOIONIA�CLASSIGm�
1"" 2-.1‘2
CLAIM NO 14- 2357 -816 POLICY NO 0509- 074 -14A LOSS DATE 07 -26 -2009 PAYMENT NO 1 18 407103 J
Coverage Description Amount COL Pay Cd DATE 01 -13 -2010'
MEDICAL PAYMENT 5433.95 600 2 AMOUNT $433.95
TIN 14- 356000972
1 I ENTERED BY POLIN, SHERRI
o 1 J AUTHORIZED BY POLIN, SHERRI
PHONE (866) 648 -0715
REMARKS 7126/2009 7
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 407103
WEST LAFAYETTE, IN "NC5, MPC INDIANA 15 -501 L025 JPMORGAN CHASE BANK, NA 56-1544/441
COLUMBUS, DH
01 -13 -2010
CLAIM ND 14- 2357 -816 INSURED POLETIKA, NICHOLAS DATE mm a n Y Y Y Y
LOSS DATE 07 -26 -2009 ON BEHALF OF CAROL POLETIKA
*EXACTLY FOUR HUNDRED THIRTY -THREE AND 95/100.: DOLLARS *433.95
Pav to the
Order of. CARMEL FIRE DEPARTMENT
2 CIVIC SQ
CARMEL IN 46032 2584`:
d IJ I/ 1 L, /)/t 0, 1 i ;U APPROVED BY
1 7 /Z- le r
CLAIM NO 14- 2357 -816 POLICY NO 0509- 074 -14A LOSS DATE 07 -26 -2009 PAYMENT NO 1 18 407 103 J
1 Cover Descri Amount COL Pav Cd 1 DATE 01 -1 -2010
1 MEDICAL PAYMENT $433.95 600 2 1 AMOUNT $433.95
TIN 14- 356000972
AUTHORIZED BY POLIN, SHERRI
PHONE (866) 648 -0715
REMARKS 7/26/2009
r STAT FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 .18 40710 J
WEST L AFrAY TTE?, IN JPMORGAN; CHASE BANK, NA 56=1544/44;
COLUMBUS :OH
rr "d >MPC.',I:NDIANA •x 50'1 LOZ�.
01 2 13-2010 n7;
ATE
CLAIM No' 14,2357-816 INSURED: POLETIKA, NICHOLAS
D nna� oo v -Ej
;L oss DATE` 07 -26- 2009 0N BEHALF OF ,CAROL POLETIKA
RI
*EXACTLY FOUR HUNDRED THIRTY -THREE AND 95/100. DOLLARS *433.95 p
m RI
Pay ro the
L, Order of. CARMEL FIRE DEPARTMENT
2 CIVIC SQ
CARMEL IN 46032-2584
E 1'j I
e.
AUTHORIZED SIGNATURE Vii
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Prescribed by State Board of Accounts City Form No 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
P ayee /1
(rc I '1 0Je T� Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4e; pap r OVerpay mei o/_. 4 4 9
az ?hJ /i
Total 5O 9
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
�Qrb� Oley IN SUM OF$ G O
36' 53 td(9-0dfilill 67L
VVme� 3l 4/( 03,Z
(0s -0
ON ACCOUNT OF APPROPRIATION_FOR
4mhulave �t /w(/ No /fry
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
FEB 1 2090
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund