184120 04/13/2010 CITY OF CARMEL, INDIANA, VENDOR: 360618 Page 1 of 1
ONE CIVIC SQUARE STEPHANIE MARSHALL CHECK AMOUNT: $299.89
ti r' CARMEL, INDIANA 46032 576 TULIP POPPLUR CREST
CARMEL IN 46033 CHECK NUMBER: 184120
CHECK DATE: 4!1312010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4347500 020110 299.89 COBRA FAMILY
Richard Marshall, Jr. Q SVP Worldwide COBRA Coupon #1 February/201 0
Coverage Tier Period Premium 0
I
-11' 1.111 1.-
BCBS HDHP/HSA Medical/Dental Plan Employee Family 02/01/2010 02/28/2010 352.81
Comments Notes: Subtotal: $352.81
Amount Paid: $0.00
Return this Coupon and Your Payment to: Coverage f or: Total Due: $352.81
Medcom Richard Marshall, Jr. Due Date: 02/01/2010
P.O. Box 10269 Total Enclosed:
Jacksonville, FL 32247-0269 578 Tulip Poplar Crest
Carmel, IN 46033 Make Check Payable to:
Medcom
www.hsabank.com
X-
RICHARD C MARSHALL JR 110
578 TULIP POPLAR CREST 79-7941759
CARMEL, IN 46033
Dart
Pay to the
Order o
01 C)CIOIIS on
_l�'� FWtk.
For Eligible Medical Expenses
For
ism
Toll Free AutomatedBankline: (800) 565 -3512
e -mail: askus @hsabank.com
Para un representante en espanol, por favor Ilamar al 866 357 -6232
Richard C Marshall Jr
578 Tulip Poplar Crest
Carmel, IN 46033 2 $2,824.54
k'1of_9 :_02101 1 $119
$1.29
2
$3.41 $2,420.58
x Description Debits Credits f Date Balance
BALANCE LAST STATEMENT 01131/2010
1ANNUAL PERCENTAGE YIELD EARNED FOR 28 DAYS IS 0.65 Total For This Total
(INTEREST EARNED DURING CYCLE PERIOD 1.29 Period Year -to -Date' it
CURRENT INTEREST RATE 0.49% Total Overdraft Fees $0.00 $0.00
[AVERAGE BALANCE FOR THIS STATEMENT'CYCLE SZ599.1Q
Total Returned-Item Fees $0.00 i" $0.00
OVERDRAFT AND RETURNED ITEM FEE DISCLOSURE INFORMATION
EFFECTIVE JANUARY 1, 2010
-t--
Prescribed by State Board o1 Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
ste �hoi I�arSha Purchase Order No.
5 79 TLA b Pop) &r Cre 4 Terms
C ar rN 1V H b Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
2- I'i0 d
Hr AA 2,010 81
Total 2
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.
I ALLOWED 20
P hQhl�ShA IN SUM OF
579 T N i le Cre_4
2�9gy
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
90 2- 62. 0 111) 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
3(J� 2040
gnature
Director of Redevelopment
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund