190848 10/13/2010 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ti ONE CIVIC SQUARE PAMELA LISTER
CHECK AMOUNT: $81.00
11598 MANSFIELD PLACE
CARMEL, INDIANA 46032
CARMEL IN 46032 CHECK NUMBER: 190848
CHECK DATE: 10/13/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 81.00 TRAVEL PER DIEMS
Prescribed by State Board of Accounts MILEAGE CLAD General Form No. 101 (1955)
TO 00E f DR.
(Governmental Unit)
Vd 2S On Account of Appropriation No. for
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE �o
20 Point Point Start Finish TRAVELED PER MIL
Ala
9
d 3 S aJ3�"a mod•
7V 2J 76
�1 V��
r9 02
J G r.e/� �i r C 7 �o
p v g 6 erL l off/ 90 �l 7 3 S ct
Auto License No. TOTALS (J
I
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, 1 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 same has been paid. 1
Date U
i
Claim No. Warrant No. I have examined the within cicdm and
hereby certify as follows;
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon statutory autho
That it is apparently correct
incorrect
On Account of Appropriation No
Disbursing Officer
O
Allowed 20 n
in the sum of 0 7 d O
o
Cn
QP
Ln
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'Q m
r-r
N
'0
(Board or Commission) N
FILED m
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a
(Offici(:l Title)
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