191363 10/27/2010 CITY OF CARMEL, INDIANA VENDOR: 364834 Page 1 of 1
ONE CIVIC SQUARE ELLEN SMITH CHECK AMOUNT: $25.00
CARMEL, INDIANA 46032 4956 LIMBERLOST TRACE
o CARMEL IN 46033
CHECK NUMBER: 191363
CHECK DATE: 10/27/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1092 4358400 25.00 PARKS DEPARTMENT REFU
PASS REFUND RECEIPT
Receipt: 531534
Payment Date: 10/18/10
Household 11348
Monon Community Center Ellen Smith Hm Ph: (317)815 -3749
Carmel IN 46032 4956 Limberlost Trace
Carmel IN 46033 Cell Ph: (317)501-7856
Phone: (317)848 -7275
Fed Tax ID #35- 6000972
Pass Details
CANCELLATION
Pass Holder: Cameron Smith Fees Tax Discount Prey Paid Cyr Paid Amount Due
Pass Type: FIT Yth M (XM FTYM), #71167 95.00 0.00 0.00 95.00 0.00
Valid Dates: 05/27/2010 to 01/14/2011 Pass Cancellation)
Pass Comments: Children ages 11 -13 may use Fitness Center, but must be under adulit supervision.
Children must be age 14+ to utilize the Fitness Center without adult supervision.
PREVIOUS NET CREDIT HOUSEHOLD BALANCE 25.00
Processed on 10 /18 /10 09:20:42 by YJG FEES CHANGED ON CANCELLED ITEMS 95.00
SURCHARGE APPLIED AGAINST CANCELLED FEES 95.00
NET AMOUNT FROM CANCELLED ITEMS 0.00
t��l V
HH BALANCE APPLIE=D TO THIS RECEIPT 25.00
I TOTAL AMOUNT REFUNDED 25.00
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 25.00 Made By V oard N With Reference
All refunds are- to S unts claim procedure a nd may take 4 -6 weeks to process. A check will be
issued. I�.o -c sh or credit r
a
Sze ig ature
Uatef Authorized Signature Date
0 (gam El T1 WR
00 19 2010
BY:
Page 1
The
monon Center stafl'In;etal5
AlCENTRAI_P PASS CANCELLATION FORM
Date: l 6
Monthly pass cancellations require at least 7 business days written notice prior to next auto payment date in Gs Lead Inivals:
order to stop the payment from being processed. All associated passes shall be cancelled effective on the date
the written notice is received by the Monon Community Center, Prorated refunds are not issued for monthly Date: L0_ l
passes.
(Circle one if refund requested) Check Refund ,dr Household Credit
*Note: Check refunds take 3- 4`weel<s toprocess. Household credit will be placed on account for credit towards future transaction,
Name of person requesting cancellation: t _C r' Today's Date:
Phone Number: Email: 1. j i fC. -�L ��•T L- 01.1 01 0, C
c?
Address:
l�� L P r tJ�- City: "r-.� Zip: Cy
Name(s) on pass(es) to be cancelled:
Type of pass(es) to be cancelled:
Reason for pass cancellation:
I have a rental locker do not have a rental locker
L.-
Passholder's Signature: t'"4
office Use On
Verified installment billing for the next month.
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
Smith, Ellen Terms
4956 Limberlost Trace Date Due
Carmel, IN 46033
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
10118/10 531534 Refund 25.00
Total 25.00
1 hereby certify that the attached invoice 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,
Smith, Ellen Allowed 20
4956 Limberlost Trace
Carmel, IN 46033
In Sum of
25.00
5
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1092 531534 4358400 25.00 1 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
21 -Oct 2010
Signature
25.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund