188000 07/21/2010 CITY OF CARMEL, INDIANA VENDOR: 364433 Page 1 of 1
ONE CIVIC SQUARE TRISH PESYNA CHECK AMOUNT: $56.00
`4 1 CARMEL, INDIANA 46032 3686 BRUMLEY WAY
CARMEL IN 46033 CHECK NUMBER: 188000
CHECK DATE: 7/21/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1092 4358400 466771 56.00 REFUNDS AWARDS INDE
PASS REFUND RECEIPT
Receipt 466771
Payment Date: 07107110
Household 3065
Moron Community Center Trish Pesyna Hm Ph: (317)815 -9171
Carmel IN 46032 3686 Brumley Way Wk Ph: (317)
Carmel IN 46033 Cell Ph: (317)614 -5519
kpesyna @indy.rr.com
Phone: (317)848 -7275
Fed Tax ID #35- 6000972
Pass Details
CANCELLATION Refund Of 56.00
Pass Holder: Ken Pesyna Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: FIT Adlt Mnthly (XM FTAM), #83773 96.00 0.00 0.00 96.00 0.00
Valid Dates: 10/06/2009 to 10/06/2010 Pass Cance
Cancel Reason: guest states pass should have been cancelled in Jan. we are researching for paperwork. pass
was not billed feb &mar. started getting billed in April 2010. refunding April May payments.
The following item reflects a payment towar s a previous receipt
Pass Holder: Derek Pesyna Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: FIT Adlt Mnthly (XM FTAM), #68764 60.00 0.00 40.00 20.00 0.00
Valid Dates 05/24/2009 to 05/2412010 Pass Cancellation)
PREVIOUS NET HOUSEHOLD BALANCE 20.00
Processed on 07/07110 16:37:18 by TLP FEES CHANGED ON CANCELLED ITEMS 172.00
SURCHARGE APPLIED AGAINST CANCELLED FEES 96.00
NET AMOUNT FROM CANCELLED ITEMS
FEES ADJUSTED ADJUSTED ON CHANGED ITEMS 0.00
qM r('t 74 gt n NET AMOUNT FROM CHANGED ITEMS 0.00
U
JUL 1 4 20 10 F HH BALANCE APPLIED TO THIS RECEIPT(,) 20.00
V TOTAL AMOUNT REFUNDED 56.00
BY. NEW NET HOUSEHOLD BALANCE 0.00
Refund of 56.00 Made By REFUND FINAN With Reference
Payment of 20.00 Made By Pass Management Credit Balance
All refunds are subject to S, a e oard rAunts claim procedure and may take 4 -6 weeks to process. A check will be
issued. No cash or credit and fund SigVtur ate Authorized Signature Date
Page 1
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.
Pesyna, Trish Terms
3686 Brumley Way Date Due
Carmel, IN 46033
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/7110 466771 Refund 56.00
Total 56.00
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
20
Clerk- Treasurer
Voucher No. Warrant No.
Pesyna, Trish Allowed 20
3686 Brumley Way
Carmel, IN 46033
In Sum of$
56.00
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #ITITLE AMOUNT Board Members
Dept
1092 466771 4358400 56.00 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
15 -Jul 2010
/50'W Dio)Vm
Signature
56.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund