187166 07/06/2010 CITY OF CARMEL, INDIANA VENDOR: 00351706 Page 1 of 1
ONE CIVIC SQUARE SCOTT BREWER CHECK AMOUNT: $141.22
r CARMEL, INDIANA 46032
CHECK NUMBER: 187166
CHECK DATE: 7/6/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 141.22 INS REFUND
COBRA monthly medical premium (employee /family) 1916.03
COBRA monthly dental premium (employee /family) 101.42
TOTAL MONTHLY PREMIUM 2017.45
Apply subsidy x 0.35
706.11
706.11 30 23.537 premium /day
23.537 x 6 days 141.22
Refund to Scott Brewer for 6 days (6/1 -6/6) during which he was still covered by health
insurance, but also paid his entire COBRA payment for the month of June.
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
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
Scott Brewer Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date 'Number (or note attached invoice(s) or bill(s))
06125110 Sbrew r062510 Scott Brewer Cobra Refund for the Month of June $141.22
Total $141.22
1 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. 06/25/10 WARRANT NO.
ALLOWED 20
Scott Br ewer
IN SUM OF
1828 Chantada La
Fort Wayne, IN 46816
$141.22
ON ACCOUNT OF APPROPRIATION FOR
301 Medic Fund
Board Members
D a INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
Sbrewer062510 301 $141.22 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund