HomeMy WebLinkAbout192243 11/23/2010 CITY OF CARMEL, INDIANA VENDOR: 364901 Page 1 of 1
ONE CIVIC SQUARE GEORGE SHANLEY
CARMEL, INDIANA 46032 13718 ADIOS PASS CHECK AMOUNT: $18.45
CARMEL IN 46032
CHECK NUMBER: 192243
CHECK DATE: 11/23/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 18.45 REFUND
Date: 11/10/2010
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CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
BiU To: GEORGE W SHANLEY ICD-9: 7802 7804 78605 7851
13718 ADIOS PASS
CARMEL, IN 46032
From: 1371$ ADIOS PASS
To: ST. VINCENTS HOSPITAL CARMEL
ANTHEM BC /BS/ 37010
Patient: GEORGE W SHANLEY XYP914183381
13718 ADIOS PASS Insurance
CARMEL, IN 46032 2 REGENCY EMPLOYEE BENEFITS
Patient No: 201000659 00459 00018 -00
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$381.55 $400.00 -18.45
CPT
Date Description Charges Credits
03/04/2010 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
03/04/2010 MILEAGE A0425 $6.55
09/28/2010 PAYMENT $200.00
11/09/2010 PAYMENT $200.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 11/10/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
X ITKN
BiU To: GEORGE W SHANLEY ICD -9: 7802 7804 78605 7851
13718 ADIOS PASS
CARMEL, IN 46032
From: 13718 ADIOS PASS
To: ST. VINCENTS HOSPITAL CARMEL
ANTHEM BC /BS/ 37010
Patient: GEORGE W SHANLEY XYP914183381
13718 ADIOS PASS Insurance
CARMEL, IN 46032 2 REGENCY EMPLOYEE BENEFITS
Patient No: 201000659 00459- 00018 -00
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM, THANK YOU,
Total Amount Total Paid Balance
$381.55 $381.55 $0.00
CPT
bate Description Charges Credits
03/04/2010 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
03/04/2010 MILEAGE A0425 $6.55
09/28/2010 PAYMENT $200.00
11/09/2010 PAYMENT $200.00
11/10/2010 REFUND -18.45
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
1y
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 f
r Por c �h q_1 l Purchase Order No.
Terms
Date Due
Invoice invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
zzzel
r
Total
I 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
ON ACCOUNT OF APPROPRIATION FOR
mb�le �lv v
Board Members
Po# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice 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
NO V 22 2010
2
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund