188039 07/21/2010 CITY OF CARMEL, INDIANA VENDOR: 00350917 Page 1 of 1
ONE CIVIC SQUARE KIM ROTT
CHECK AMOUNT: $17.60
CARMEL, INDIANA 46032
CHECK NUMBER: 188039
CHECK DATE: 7/2112010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4343004 17.60 TRAVEL PER DIEMS
PRESCRMED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 101 (1986)
MILEAGE' CLAIM
TO !l rn
(GOVERNMENTAL UNIT)
ON ACCOUNT OF APPROPRIATION NO. FOR
'O .k u. r±
(OFFICE DEPARTMENT OR IN UTION)'
DATE FROM TO SPEEDOMETER
REA DING AUTO MILEAGE
NATURE OF BUSINESS MILES
�un ��r 0(Q POINT POINT START FINISH TRAVELED
PER MILE
Daru t
11 36 9 ':4 1 /D
AUTO LICENSE NO. TOTALS a
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, I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits
and that no part of the I same has been paid.
Date
Claim No. Warrant No. I have examined the within claim and hereby
IN FAVOR OF certify as follows:
That it is in proper form.
uaL� That it is duly authenticated as requirec
by law
That it is based upon statutory authority
That it is apparently correct
f incorrect
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i Disbursing Officer
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