185025 04/28/2010 CITY OF CARMEL, INDIANA VENDOR: 360618 Page 1 of 1
1 ONE CIVIC SQUARE STEPHANIE MARSHALL
CHECK AMOUNT: $299.84
CARMEL, INDIANA 46032 578 TULIP POPPLUR CREST
bi %fi CARMEL IN 46033 CHECK NUMBER: 185025
CHECK DATE: 4128/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4347500 299.89 GENERAL INSURANCE
Richard Marshall, Jr. SVP Worldwide COBRA Coupon #2 March/2010
Coverage Tier Ppr[od Premium
BOBS HDHPIHSA Medical/Dental Plan Employee Family 03/01/2010 03131/2010 352.81
Comments Notes:
Subtotal: $352.81
Return this Coupon and Your Payment to: Coverage f or: Total Due: $352.81
Medcom Richafd Marshall, Jr. Due Date: 03/01/2010
P.O. Box 10269 Total Enclosed:
Jacksonvtda, FL 32247-0269 578 Tulip Poplar Crest
Carmel, IN 46033 Make Check Payable to: 551-01
[xi n r~=."u. �n
578 TULIP POPLAR CREST 79-794/759
CARMEL, IN 46033
Date
Pay to the
Order
tars
e
Tl Free Automated Bankline: (800) 565 -3512
e -mail: askus @hsabank.com
Richard C Marshall Jr Para un representante en espanol, por favor Ilamar al 866 -357 -6232
Rpm
578 Tulip Poplar Crest
Carmel, IN 45033 $2 ,420.58
1' Of 1 0341 -034 1 7 1 "'$0.51
$0.51 l 3� $616.75'-'
$3.92` $1,804.34 r
DesCriptEOn Credits c x D e 'BalaRCe
BALANCE LAST STATEMENT 02/28/2010
ANNUAL PERCENTAGE YIELD EARNED FOR 31 DAYS IS 0.30P/* Total For This Total'
INTEREST EARNED DURING CYCLEPERIOD 0 5t Period Yearto•Date
CURRENT INTEREST RATE 0 29 Total Overdraft Fees; $O.6O $0:00
AVERAGE BALANCE FOR THIS STATEMENT CYCLE. $1,999.12
Total Returned Item Fees $0.00
OVERDRAFT AND RETURNED ITEM FEE DISCLOSURE INFORMATION
EFFECTIVE JANUARY 1, 2010
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form Mo. 203 (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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
v
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.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
2 3e; 3y75o0 29 9,i 9 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
y -22 20 Ad
Signature
®(rector of RledevalOn17 wd
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund