188022 07/21/2010 CITY OF CARMEL, INDIANA VENDOR: 364435 Page 1 of 1
p 0 ONE CIVIC SQUARE AMY RAFALKO CHECK AMOUNT: $79.20
CARMEL, INDIANA 46032 12464 GLENBURGAN OR
CARMEL IN 46032 CHECK NUMBER: 188022
CHECK DATE: 7/2112010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1082 4358400 466397 79.20 REFUNDS AWARDS INDE
ACTIVITY REFUND RECEIPT
Receipt 466397
Payment Date: 07!07!10
Household 843
Monon Community Center Amy Rafalko Hm Ph: (317)575 -0858
Carmel IN 46032 12464 Glenburgan Dr.
Carmel IN 46032 Cell Ph:
amy511999 @yahoo.com
Phone: (317)848 -7275
Fed Tax ID #35- 6000972
Enrollment Details
ROSTER CHANGE Refund Of 39.60
Enrollee Name: Andrew Rafalko Fees Tax Discount Prev Paid Cur Paid Amount Due
Activity Number: 476009 -10 Skyhawks Sports 59.40 0.00 59.40 0.00 0.00
Enrollment Date: 03/01/2010 (Enrolled)
Class Location: Skate Park Class Dates. 06/2112010 to 06/25/2010
Monon Community Cntr 9:00A to 11:OOA
M,Tu,W,Th,F
Carmel, IN 46032 Scheduled Sessions: 5
(317)848 -7275
ROSTER CHANGE Refund Of 39.60
Enrollee Name: Chris Rafalko Fees Tax Discount Prev Paid Cur Paid Amount Due
Activity Number: 476009 -10 Skyhawks Sports 59.40 0.00 59.40 0.00 0.00
Enrollment Date: 03/01/2010 (Enrolled)
Class Location: Skate Park Class Dates: 06/21/2010 to 06/25/2010
Monon Community Cntr 9:OOA to 11:OOA 7 TZ
M,Tu,W,Th,F 5�1
Carmel, IN 46032 Scheduled Sessions 5 �j
(317)848 -7275 f]t' J 1 2 201
BY:.......................
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 07107/10 14:22:33 by BJJ FEES ADJUSTED ON CHANGED ITEMS 7920
NET AMOUNT. FROM CHANGED ITEMS 79.20- t
TOTAL AMOUNT REFUNDED 79.20 4
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 79.20 Made By REFUND FINAN With Reference
All refunds are ubject to State Board of Accounts claim procedure and may take 4 -6 weeks to process. A check will be
issued. No ca or credit card refunds.
Authoriz 'nature Date 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.
Rafalko, Amy Terms
12464 Glenburgan Dr Date Due
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
717110 466397 Refund 79.20
Total 79.20
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,
Rafalko, Amy Allowed 20
12464 Glenburgan Dr
Carmel, IN 46032
In Sum of
79.20
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO# or INVOICE NO. ACCT#ITITLE AMOUNT Board Members
Dept
1082 -98 466397 4358400 79.20 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
Signature
79.20 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund