186229 06/09/2010 CITY OF CARMEL, INDIANA VENDOR: 363569 Page 1 of 1
ONE CIVIC SQUARE MICHAEL CALVERT
CARMEL, INDIANA 46032 C/O BROOKSHIRE GOLF COURSE CHECK AMOUNT: $7.50
CHECK NUMBER: 186229
CHECK DATE: 6/912010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 7.50 TRAVEL PER DIEMS
Prescribed by State Board of Accounts M ILEAGE General Form No. 101 (1955)
TO L 6 Cl 'S U DR.
(Governmental Unit)
6 In
On Account of Appropriation No. for
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS I AUTO MILES MILEAGE
20 f Point Point Start Finish TRAVELED PER MILE
7 5�
l V
Z� L 'PAR +llJ Z `3 t J S d
Auto License No. F TOTALS
f
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, 1 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
i
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
�r That it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon statutory autho
�ti That it is apparently correct
I incorrect
On Account of Appropriation No. 6 7 1 for
Disbursing Officer
O
Allowed 20
in the sum of
o m
�a
b�
0 00
(Board or Commission) r
FILED tD
Fn
n
n
0
a
0
(Official Title)
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