182586 02/17/2010 CITY OF CARMEL, INDIANA VENDOR: 363898 Page 1 of 1
ONE CIVIC SQUARE THOMAS VALEK
s CHECK AMOUNT: $237.50
CARMEL, INDIANA 46032 484 E CARMEL DR, BOX 124
ti�.o� `off CARMEL IN 46032 CHECK NUMBER: 182586
CHECK DATE: 2/17/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4358400 373848 237.50 REFUNDS AWARDS INDE
PASS REFUND RECEIPT
Receipt 373848
Payment Date: 01/11/10,
Household 32647
.orchard Park Element Thomas Valek
10404 Orchard Park Drive South 484 E Carmel Or
Indianapolis IN 46280 Box #124 Cell Ph: (517)515-3425
Carmel IN 46032
'Phone: (317)848 -7275 tevalek @comcast.net
Fed Tax ID #35- 6000972
Pass Details
CANCELLATION Refund Of 237.50
Pass Holder: Ethan Valek Fees Tax Discount Prey Paid Cur Paid Amount Due
Pass Type: 20 -Visit (ESE20V) #93970 12.50 0.00 12.50 0.00 0.00
Valid Dates: 08/11/2009 to 05/27/2010 Pass Cancellation)
Pass Visit into: Number of Visits: 20
Cancel Reason: cancelled within 24hrs
GIL_Code. Description Account. Number CstCntr De Acc Amou_n.l
999999 Control Account (AP) Enter Control Acct CNTRL Control Account (AP) Enter Control Acct here 237.50 DR
The REVENUE account was DEBITED and the CONTROL account was CREDITED on the day of the refund.
Finance will have to DEBIT the CONTROL account for the amounts listed above after the checks have been written to the customers.
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 01111110 13:52:47 by NNL rte' f FEES CHANGED ON CANCELLED ITEMS 237.50-
r g!� 1 NET AMOUNT FROM CANCELLED ITEMS
20 237,50
L�J 0 p TOTAL AMOUNT REFUNDED 237.50
33Y: NEW NET HOUSEHOLD BALANCE 0.00
Refund of 237.50 Made By REFUND FINAN With Reference
All refunds are subject to State Board of Accounts claim procedure and may take 4 -5 weeks to process. A check will be
issued, Na cash or credit card refunds.
uth iz Signature Date Authorized Signature Date
I
Page 4 1
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
Vallek, Thomas Terms
484 E Carmel Dr., Box 124 Date Due
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
1I11I1fl 373848 Refund 237.50
Total 237.50
1 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.
Valek, Thomas Allowed 20
484 E Carmel Dr., Box 124
Carmel, IN 46032
In Sum of$
237.50
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO# or INVOICE NO. ACCT #!TITLE AMOUNT Board Members
Dept
1081 -6 373848 4358400 237.50 l 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
11 -Feb 2010
l/ &W9 //1 L1 IZ4
Signature
237.50 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
1