HomeMy WebLinkAbout190794 10/13/2010 CITY OF CARMEL, INDIANA VENDOR: 00351325 Page 1 of 1
0 ONE CIVIC SQUARE DAVID HUFFMAN
CARMEL, INDIANA 46032 C/0 STREET DEPARTMENT CHECK AMOUNT: $5,000.00
C/0 STREET DEPARTMEN CHECK NUMBER: 190794
CHECK DATE: 10/1312010
DEPARTMENT A CCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 5,000.00 ADOPTION
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CITY OF CARMEL c�,z��c
ADOPTION ASSISTANCE CLAIM FORM
SEE REVERSE SIDE FOR INFORMATION AND INSTRUCTIONS l
Employee Name (First MI Last):
Department: S�{ i/ Q e 4—
Social Security Number: S C Work Phone: 7' 7 d U�/
Employee ID Number: 57 3 Home Phone:
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Child's Name: S o h t a "I Pr f4 Date of Birth:
SSN (if known): Final Adoption Date: /C)
Attach
Attach copy of adoption decree if adoption has been finalized.
Date: F 7� c Paiid To: Services Rendered: Amount:
1V 1 %ia" ayeA e- A /4 re W )D
5A//o 5! A ID
q110 I t t I t o f &7 I
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OCT 1 1 2010
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Attach original itemized receipts in J.S. dollars for all expenses listed above. No reimb ttpropriate documentation.
Attach separate sheet of paper for additional expenses.
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I hereby request reimbursement for the adoption expenses listed above. By signing below, I certify that:
Check appropriate box: The child identified above has been placed in my home pursualy to adoption or
The adoption of the child identified above has been finalized [A and
To the best of my knowledge, each expense listed above is a qualified adoption expense under the City of Carmel
Adoption Assistance Program; and
All statements and documentation relating to this claim are true and complete.
I understand that incomplete or inaccurate information may adversely affect my eligibility for benefits through the
Adoption Assistance Program.
Employee Signature: F Date: C //j
r
Form HR103 (1/08) OlW cial form cannot be altered or substituted.
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995}
s 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
David Huffman Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
10/11/10 092910 Adopt Asst. Adoption Assistnace Reimbursement
Total $5,000.00
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 Ng ojjj,jo WARRANT NO.
ALLOWED 20
David Huffman IN SUM OF
$5,000.00
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
Board Members
PO# or 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
092910 Adopt As t. 301 $5,000.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund