191124 10/27/2010 CITY OF CARMEL, INDIANA VENDOR: 364832 Page 1 of 1
Q� ONE CIVIC SQUARE JASON BLACK CHECK AMOUNT: $85.50
vr` CARMEL, INDIANA 46032 362 TERRENTS COURT
CARMEL IN 46032 CHECK NUMBER: 191124
CHECK DATE: 10/2712010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1092 4358400 85.50 PARKS DEPARTMENT REFU
PASS REFUND RECEIPT
Receipt 532531
Payment Date: 10/22/10
Household 20023
Carmel Clay Parks Recreation Jason Black H Ph: (317)816 -0111
1235 Central Park Drive East 362 Terrents Ct. Wk Ph: (317)688 -3428
Carmel IN 46032 Carmel IN 46032 Cell Ph:
Phone: (317)848 -7275 jmblack661 @aol.com
Fed Tax ID #35- 6000972
Pass Details
CANCELLATION Refund Of 85.50
Pass Holder: Jason Black Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp 10 HH Prim (CORP 10H), #106603 1,218.70 0.00 0.00 1,218.70 0.00
Valid Dates: 05/12/2010 to 05/12/2011 Pass Cancellation)
Cancel Reason: Guest request.
CANCELLATION
Pass Holder: Misti Black Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp HH (CORP HH #109813 0.00 0.00 0.00 0.00 0.00
Valid Dates: 06113/2010 to 05/12/2011 Pass Cancellation)
Pass Comments: Children must be age 11 or older to utilize the pools and /or gymnasium unaccompanied by an
adult.
Children ages 11 -13 may use Fitness Center, but must be under adullt supervision.
Children must be age 14+ to utilize the Fitness Center without adult supervision.
Cancel Reason: Guest request.
CANCELLATION
Pass Holder: Isabelle Black Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp HH (CORP HH #109815 0.00 0.00 0.00 0.00 0.00
Valid Dates: 06/13/2010 to 05/12/2011 Pass Cancellation)
Cancel Reason: Guest request.
CANCELLATION
Pass Holder: Ashlynn Black Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp HH (CORP HH #109817 0.00 0.00 0.00 0.00 0.00
Valid Dates: 06/13/2010 to 05/12/2011 Pass Cancellation)
Cancel Reason: Guest request.
CANCELLATION
Pass Holder: Anna Black Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp HH (CORP HH #109818 0.00 0.00 0.00 0.00 0.00
Valid Dates. 06/13/2010 to 05/1212011 Pass Cancellation)
Cancel Reason: Guest request.
D,
2 0
BY:
Page 1
PASS REFUND RECEIPT
Receipt# 532531
Payment Date: 10/22/2010
Household 20023
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 10/22/10 13:46:27 by ABK FEES CHANGED ON CANCELLED ITEMS 1,304.20
SURCHARGE APPLIED AGAINST CANCELLED FEES 1,218.70
NET-AMOUNT FROWCANCELL ^'ED ITEMS 85;50
TOTALrAMOUNT= ,'REFLINDED 85.50
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 85.50 Made By REFUND FINAN With Reference
All refunds are subject t State Board of Accounts claim procedure and may take 4 -6 weeks to process. A check will be
issued. No cash or cre card refunds.
Author" Ee 5ign ure Date Authorized Signature Date
®v
Page 4 2
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.
Black, Jason Terms
362 Terrents Ct Date Due
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s} or bill(s)) Amount
10/22/10 532531 Refund 85.50
Total 85.50
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.
Black, Jason Allowed 20
362 Terrents Ct
Carmel, IN 46032
In Sum of
85.50
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1092 532531 4358400 85.50 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
85.50 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund