192102 11/23/2010 CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
ONE CIVIC SQUARE HINCKLEY SPRINGS
CARMEL, INDIANA 46032 PO BOX 660679
CHECK AMOUNT: $35.50
2 DALLAS TX 75266 -0579
CHECK NUMBER: 192102
CHECK DATE: 11/2312010
DEPARTMENT ACCOUNT PO NUMBER INV NUMBER AMOUNT DESCRIPTION
1301 4239099 35.50 17220042677859
1- 800 -4- WATERS (492 -8377) www.HinckleySprings.com
Upcoming Delivery Dates V Ver!
November December January Bottled Water Filtration Coffee
Thursday, 25 Thursday, 9 Thursday, 6
Thursday, 23 Thursday, 20 Put a smile on your employees' faces by starting your
office coffee service. From single -serve coffee machines
to energy saving commercial brewers, we will provide you
with the perfect selection of products to brew the perfect
cup. Callus today!
Customer Account 17220042677859
KIM ROTT Invoice Date: 11 -13 -10
CARMEL CITY COURT
1 CIVIC SQ Invoice 2677859 111310
CARMEL, IN 46032 Purchase Order
Date Transaction Details Qty. Each Amount
Previous Balance 55.50
11 -08 -10 P191231 Payment Check 191231 Thank You -55.50
Remaining Balance 0.00
R102922494748 WHITE HOT AND COLD COOLER RENTAL 1.0 13.50 13.50
10 -28 -10 T103013042006 HINCKLEY SPRINGS 5G DRINK NON -SPILL 2.0 9.99 19.98
5.0 GAL BOTTLE DEPOSIT 2.0 6.00 12.00
5.0 GAL BOTTLE RETURN -2.0 6.00 -12.00
Rec'd By: Not Available or Refused
11 -11 -10 57951248 ENERGY SURCHARGE 1.0 2.02 2.02
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 your next delivery, pay your bill and much more. Log on today!
30355 -P -0034
Previous Balance Payment Total New Charges Pay This Amount
$55.50
$55.50 $35.50 c 35.5o
0 Write the complete account number on your check. Detach remittance and mail with payment in the enclosed envel To pay online go to wwwAnckleySprings.com
How to Read Your Statement Important Monthly Promotions:
p4- D-, we Deliver' Register online for access to your
jvly a90A Augmt HQ9 account. You can view and pay your bill,
Delivery Calendar: M 'TySp N m a'nree check delivery schedule and order
Your scheduled deliveries for
the next three months. products all online.
Customer Account Number: Bottle Deposits:
For prompt service, please use this Highlights bottle deposits and returns.
number when referring to your account.
Easy to Pay:
Pay your invoice through the mail, online at
Summary: m° www.water.com or call us to expedite your
Previous balance and posted remittance with automatic credit card payments
payments since last bill.
Total New Charges:
This information provides totals for Mail Remittance With Payment To:
various products and transactions. "m Please detach remittance and mail
c,4•- using business envelope provided.
Important Monthly Message
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 indicated 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 lve our letter, us the following information: OPT OUT NOTICE: If you do not wish to participate in this check conversion
y g g 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 ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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.
a 5
1 Terms
_0 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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.
ALLOWED 20
IN SUM OF
0 s 7 l
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT I hereby certify that the attached invoice(s), or
0 M 7 ��]U .JS 5� bill(s) is (are) true and correct and that the
1 /I3in materials or services itemized thereon for
l which charge is made were ordered and
received except
20/(,
ignature
le
Cost distribution ledger classification if
claim paid motor vehicle highway fund