190301 09/29/2010 CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
ONE CIVIC SQUARE HINCKLEY SPRINGS
CARMEL, INDIANA 46032 PO BOX 660579
CHECK AMOUNT: $35.50
DALLAS TX 75266 -0579 CHECK NUMBER: 190301
CHECK DATE: 9/29/2010
DEPARTMENT ACCO PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4239099 2677859 35.50 OTHER MISCELLANOUS
1- 800-4- WATERS 492 -8377 www.Hinckleygprings.com
Upcoming Delivery Dates
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September October November Spnngs: Bottled Water •Filtration •Coffee
Thursday, 30 Thursday, 14 Thursday, 11 Help us make a difference in the fight against breast
Thursday, 28 cancer. From now through December 31 st, 2010, for every
referred customer who starts new service with any Komen
Budget Plan, we will donate $30 to Susan G. Komen for the
Cure. Visit Water.com /KomenReferral todayl
Customer Account 17220042677859
KIM ROTT Invoice Date: 09 -18 -10
CARMEL CITY COURT Invoice 2677859 091810
1 CIVIC Purchase Order M
CARMEL, I N 46032
Date Transaction Details Qty. Each Amount
Previous Balance 115.40
08 -23 -10 P188359 Payment Check 188359 Thank You -45.55
09 -15 -10 P189367 Payment Check 189367 Thank You -69.85
Remaining Balance 0.00
8102362494748 WHITE HOT AND COLD COOLER RENTAL 1.0 13.50 13.50
09 -16 -10 56185571 ENERGY SURCHARGE 1.0 2.02 2.02
09 -16 -10 T102593042007 HINCKLEY SPRINGS 5G DRINK NON -SPILL 2.0 9.99 19.98
5.0 GAL BOTTLE RETURN -2.0 6.00 -12.00
5.0 GAL BOTTLE DEPOSIT 2.0 6.00 12.00
Rec'd By: Not Available or Refused
Total New Charges 35.50
Managing your account is now at your fingertips. Take advantage of many time- saving
options available on water.com. Save paper when you sign up for elnvoice, order additional
products, check y our next delive ,_pay bill and much more. Lo on toda
30356 -P -0035
Previous Balanee Payment Total New Charges r Pay E
$115.40 $115.40 $35.50 r-
Q Write.the.com lete.account number-on. our-check.. Detach. remittance .and.mail.with.payment in.the. enclosed. envelope ._T.o.pay_online,go.to_ -__w 0
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How to Read Your Statement Important Monthly Promotions:
we Delver' Register online for acces L your
June]003 lury�oo5 Au4ult 10M BoW weie'fuiratm'Cm
Delivery Calendar account. You can view and pay you, bill,
Your scheduled deliveries for m" x check delivery schedule and a`der 3
the next three months.
products all online.
Customer Account Number: Battle Deposits:
For prompt service, please use this a Highlights bottle deposits and returns.
number when referring to your account.
Easy to Pay:
Pay your invoice through the mail, online at
Summary. www.water.com or tali us to expedite your
Previous balance and posted remittance with automatic credit card payments
payments since last bill.
o -o+
Total New Charges:
This information provides totals for Mail Remittance With Payment To:
various products and transactions. Please detach remittance and mail
„u:roa s? s I y`^j using business envelope provided.
i,n dI Al 11,1
Important Monthly Message N5111E
Billing Rights Summary Electronic Funds Transfer Notice
In case of Errors or Questions About Your Bill: If you pay by check, it will be converted into an "Electronic Funds Transfer”
If you think your bill is incorrect, or if you need more information about a (EFT), a process in which your financial institution is electronically instructed to
transaction on your bill, write us as soon as possible on a separate sheet, at transfer funds from your account to ours in lieu of processing the check. By
P.O. Box 660579, Dallas,TX 75266 -0579. We must hear from you no later sending your completed check to us, you authorize us to use the account
than 60 days after we sent you the first bill on which the error or problem information therein to create an EFT for the amount indlcated on the check. If
appeared. Your bill shall be deemed correct unless disputed within 60 days the EFT cannot be processed for technical or other reasons, you authorize us
from receipt. You can telephone us, but doing so will not preserve your rights. to process an image replacement document, draft, or copy of your check.
In your letter, give us the following information: OPT OUT NOTICE: If you do not wish to participate in this check conversion
program, please write to us on a separate sheet at:
Your name and complete account number. P.O. Box 660579, Dallas, TX 75266 -0579.
The dollar amount of the suspected error.
Describe the error and explain why you believe there is an error. If you need Insufficient Funds Notice
more information, describe the item you are unsure about.
If your check is returned for insufficient or uncollected funds (NSF), your signature
on your check gives us permission to debit your checking account electronically
You do not have to pay any amount in question while we are investigating, but for the uncollected amount. Payment by check constitutes your acceptance of
you are still obligated to pay the amount of your bill that is not in question. While these terms.
we investigate your questions, we cannot report you as delinquent or take any
action to collect the amount you question.
We appreciate your business.
As a food product, bottled water is subject to rules and regulations promulgated by the Federal Food and Drug Administration (FDA).
For further information, please write DS Waters of America, Inc. at P.O. Box 660579, Dallas, TX 75266 -0579.
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An 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.
D Lv(0't5 Terms
c c-a 7 a6 d S7 I Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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
&A
Board Members
PO# or DEPT INVOICE NO. ACCT /TITLE AMOUNT I hereby certify that the attached invoice(s), or
39 0, 3S.JZ 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
'7 20) U
i n u re
L
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund