187348 07/07/2010 CITY OF CARMEL, INDIANA VENDOR: T357856 Page 1 of 1
10� ONE CHIC SQUARE KATIE JACOBSEN CHECK AMOUNT: $150.00
e ®s CARMEL, INDIANA 46032 5772 MEADOWLARK DR
CARMEL IN 46033 CHECK NUMBER: 187348
CHECK DATE: 7/7/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1096 4358400 457629 150.00 REFUNDS AWARDS INDE
ACTIVITY REFUND RECEIPT
Receipt 457629
Payment Date: 06/29/10
Household 9825
Monon Community Center Katie Jacobsen Hm Ph: (317)846 -4034
Carmel IN 46032 5772 Meadowlark Place
Carmel IN 46033 Cell Ph:
john-jacobsen@sbcglobal.net
Phone: (317)848 -7275
Feb Tax ID #35- 6000972
Refund Details
Orio Bal Refund New Bal
Module: Activity Registration 150.00- 150.00 0,00
PREVIOUS NET HOUSEHOLD BALANCE 150.00
Processed on 06/29/10 16:04:41 by LVA NEW REFUND AMOUNT 150.00
TOTAL REFUNDABLE AMOUNT 150.00
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 150.00 Made By REFUND FINAN With Reference advanced request
All refunds are subject to State Board of Accounts claim procedure and may take 4 -6 weeks to process. A check will be
issue cash or credit card refunds.
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Authorized Sig ure Date Authorizeh Signature Date
JU 0 2010
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ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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
Purchase Order No.
Jacobsen, Katie Terms
5772 Meadowlark Place Date Due
Carmel, IN 46033
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
6/29/10 457629 Refund 150.00
Total 150.00
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
1 20
Clerk- Treasurer
Voucher No. Warrant No.
Jacobsen, Katie Allowed 20
5772 Meadowlark Place
Carmel, IN 46033
In Sum of
150.00
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1096 -42 457629 4358400 150.00 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
2 -Jul 2010
Signature
150.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund