187368 07/07/2010 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $50.00
CARMEL IN 46032 CHECK NUMBER: 187368
CHECK DATE: 7/7/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 JUNE 50.00 MILEAGE
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Prescribed by State Board of Accounts MILEAGE C LAI BV1 General Form No. 101 (1955)
TO C�IC� /G q'L DR.
(Governmental nit)
On Account of Appropriation No. for
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING' NATURE OF BUSINESS AUTO MILES MILEAGE
20 _ZQ_ Point Point Start Finish TRAVELED PER MILE
U i C 4
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/J 2_ 4,1-s e( /mod
!S V61 V_ LU
99 P62
110 oc)
v
Auto License No. TOTAL'S :�2��
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 Ily due, after
allowing all just credits, and that no part of the same has been paid.
r
Date 6 7
Claire No. Warrant No. I have examined the within cl= and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon statutory autho correct
E L That it is apparently incorrect
On Account of Appropriation No �n for
Disbursing Officer
O
Allowed 20
in the sum of o
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CD
(Board or Commission) Imo"
FILED
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(Official Title)
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