185367 05/11/2010 CITY OF CARMEL, INDIANA VENDOR: 360487 Page 1 of 1
ONE CIVIC SQUARE CARLA NEWCOMER
CARMEL, INDIANA 46032 1966 WILLIAMS GLEN BLVD CHECK AMOUNT: $14.00
ZIONSVILLE IN 46077 CHECK NUMBER: 185367
CHECK DATE: 5/11/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1180 4343004 14.00 TRAVEL PER DIEMS
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PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 101 (1966)
MILEAGE CLAIM
TO T
�JC�
(GO ERN AL UNI Y 3 n
ON ACCOUNT OF APPROPRIATION NO. Y 12� FOR �A 4j LL
(OFFICE, BOARD, DE MEN OR INSTITUTION)
SPEEDOMETER
DATE FROM TO READING NATURE OF BUSINESS MILE MILEAGE
POINT POINT START FINISH TRAVELED PER MILE
So f33 '7 o
AUTO LICENSE NO. TOTALS /,fl Q a
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953 I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits
and That no part of the same has been paid.
Date
Claim No. Warrant No. I have examined the within claim and hereby
IN FAVOR OF certify as follows:
0 That it is in proper form.
That it is duly authenticated as required
by law
That it is based upon statutory authority.
That it is apparently
correct
incorrect
'S� Disbursing Officer
On Account of Appropriation No. L -760 4f or
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