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182719 03/02/2010
CITY OF CARMEL, INDIANA VENDOR: 360618 Page 1 of 1 a, ONE CIVIC SQUARE STEPHANIE MARSHALL CHECK AMOUNT: $299.89 CARMEL, INDIANA 46032 578 TULIP POPPLUR CREST CARMEL IN 46033 CHECK NUMBER: 182719 CHECK DATE: 3/2/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4347500 10110 299.89 MEDICAL /DENTAL Richard Marshall. Jr. SVP Worldwide COBRA Coupon #1 J,i n u a r y/ ?(1 tCSS HDHP/HSA Mled.t a.'. Plan E i i i F) e e F rT i i ly /0 1 0, 0 �'3 ljol-11 0 5 2. 6 Comments,' Notes: S! lbtotai: $352,8 Amoun! Paid: SO,Ofj ;71urn this Coupon and Your Payment to: Coverage for: Total Due: Richard Marshall. Jr, Due Date: 01101/201 10269 Total Enclosed, FL 32247-0269 578 Tulip Poplar Crest Carrel. IN 46033 Make Check Payable to: e-mail: askus @hsabank.com Richard C Marshall Jr Para un representante en espanol, por favor Ilamar at 866- 357 -6232 578 Tulip Poplar Crest h t qv Carmel, IN 46033 $8 .d.v. M n r t r ?T 1'of'1 ©1101= -01131 1 $2.12 Pe. n 1, l 2 $352.'81 $2' 12 $2,824:54 ACCOUNT , �se....^•e •DCSCCE�4r10EE` �x x�k r. ,xs,� ",:x,.sk-.....,c..:; '``�Deblts .'rte:' CE'CE$Et5 :...1� 'Date ..t ?'BdIA11CC BALANCE LAST STATEMENT 12/31/2009 ANNUAL PERCENTAGE YIELD EARNED.FOR 31 DAYS IS 0.85% Total ForThls Total INTEREST EARNED DURING CYCLE PERIOD 2.12 Period Year-to -Date CURRENT INTEREST RATE 0-8 Total Overdraft Fees $0.00 10.00 AVERAGE BALANCE FOR THIS STATEMENT CYCLE: $2,952:91 Total Returned Iteni Fees 50.00 $0.00 OVERDRAFT AND RETURNED ITEM FEE DISCLOSURE INFORMATION EFFECTIVE J NUARY 1, 2010 / 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. S 7 c? T jz �U �r �v�s� Terms �G j"'r°�, 1,-7 17 6, !!�'3 3 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) `t Total 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. <iF; 20 Clerk- Treasurer 'VOUCHER NO. WARRANT NO. L r� ALLOWED 20 IN SUM OF ON ACCOUNT OF APPROPRIATION FOR �2/* SDD Board Members PO# or DEPT INVOICE NO. ACCT /TfTLE AMOUNT 1 hereby certify that the attached invoice(s), or /a a q V75o0 2) ,9Sq bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and ,Z' received except f f� 2 Si ature Director of Opemdons Title Cost distribution ledger classification if claim paid motor vehicle highway fund