186926 06/23/2010 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
0 ONE CIVIC SQUARE PAMELA LISTER
s, �a CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $46.50
CARMEL IN 46032
CHECK NUMBER: 186926
CHECK DATE: 6/23/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 46.50 TRAVEL PER DIEMS
Prescribed by State Board of Accounts
General Form No. 101 (1955)
MILEAGE CLAIM
TO 60 I CJ- DR.
(Governmental Unit)
On Account of Appropriation No. for
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE �d
20 /0 Point Point Start Finish TRAVELED PER MILE
5
o to 0
o 5 3 5-a
3�Z c?
v o c 6 57 44 11,12971 j SD
Jo
a o v�
11 d
o
f s-d
i o J616b 4
o/
&Z o
t p
s p n
a as
12 old'/ s�1 0 a
16 zz 7 a cT�
o /C r 7 v c�
o r 5 -0
Auto License No. TOTALS
I
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
Clairn No, Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
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
l�
On Account of Appropriation No. Z(; for
1 C v J ,r-� Disbursing Officer
Allowed 20
in the sum of a
X�
n
(D
'0
CD
C
Q
(Board or Commission) C)
(D
FILED (D
a m
O
(D
0 N
v
(Official Title)
Co
O N Q