190039 09/14/2010 a CITY OF CARMEL, INDIANA VENDOR: 364709 Page 1 of 1
0 ONE CIVIC SQUARE JAMES WALKER CHECK AMOUNT: $344.65
CARMEL, INDIANA 46032 4744 MINTON COURT
CARMEL IN 46033 CHECK NUMBER: 190039
CHECK DATE: 9/14/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 344.65 AMBUL REFUND
Date: 08/31/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
°sue
A Is
BRI To: JIM WALKER ICD -9: 78907 7295 E8130
4744 M I NTON CT
CARMEL, IN 46033
From: 126TH KINZER AV
To: ST. VINCENTS HOSPITAL CARMEL
1 OHIO CASUALTY
Patient: JIM WALKER CLM #22016766
4744 MINTON CT Insurance
CARMEL, IN 46033- 2
Patient No:
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$344.65 $689.30 344.65
CPT
Date Description Charges Credits
01/16/2010 BASIC LIFE SUPP- EMERGENCY A0429 5325.00
01/16/2010 MILEAGE A0425 $19.65
03/30/2010 PAYMENT $344.65
08/26/2010 COMMERCIAL INSURANCE PAYMENT $344.65
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 08/31/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal lD# 356000972
Bill To: JIM WALKER ICD -9: 78907 7295 E8130
4744 MINTON CT
CARMEL, IN 46033
From: 126TH KINZER AV
To: ST. VINCENTS HOSPITAL CARMEL
OHIO CASUALTY
Patient: JIM WALKER CLM #22016766
4744 MINTON CT Insurance
CARMEL, IN 46033- 2
Patient No:
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$344.65 $344.65 $0.00
CPT
Date Description Charles Credits
01/16/2010 BASIC LIFE STJPP- EMERGENCY A0429 $325.00
01/16/2010 MILEAGE A0425 $19.65
03/30/2010 PAYMENT $344.65
08/26/2010 COMMERCIAL INSURANCE PAYMENT $344.65
08/31/2010 REFUND 344.65
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Return this portion with your payment
Payable To: CARMEL FIRE DEPARTMENT
201000240 JIM WALKER $344.65
Run slate I-
01J1612010��� Y1JA� Amount Paid l
3 d �GiO
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
James N. Walker 07 98 20 6n4o 2831
Vickie L. Walker
4744 Minton
Carmel, IN 460303
3
317 705 -0737
PAY
TO THE
ORDER OF
65 DOLLARS
FOR
2113 1
VER IFYi7HE AUTHENTICITY:O THIS MULTI -TONE SECURITY DOCUMENT. CHEL;K BNC G AREA COLOR GRADUALLY EROM'.TOPTO, BOTTOM.
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to Claim No. LNI EXP "1, "AU 2 2 -:016 7`6 6 W
the *CARMEL FIRE DEPT*
order 2'' CIVIC. SQUARE Far: JAMES ;WALKER j
of CARMEL IN 46032
tr*+ r* sr****•**.* *.*+r,r**�tww** **w *rrwww*w *xw
Insured WALKER •.1II JAMES N: &a VICKIE L
u ®8635739311° 1 :0422009h0`: 0000167363na
Nis,,; 'THE!ORIGINAL-cl OGUMENT. HAS/ kiREFEECTIVE-VI4ATERNI'ARKION'' THE" .BACK 11OLD�AT AN' 4NGLET0WIEWWHEhf#GHECLCIEVG ;THE ENDORSEMENT`; -'jj
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1935)
CITY OF CARMEL
invoice or 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.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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.
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
A2� AZ6j(" 4
Board Members
PO# INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I 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
5EP I 2n in
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund