192492 12/07/2010 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
O ONE CIVIC SQUARE PAMELA LISTER CHECK AMOUNT: $31.50
1. CARMEL, INDIANA 46032 11598 MANSFIELD PLACE
CARMEL IN 46032 CHECK NUMBER: 192492
CHECK DATE: 12/7/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 31.50 TRAVEL PER DIEMS
Prescribed by State Board of Accounts MILEAGE CLAIM General Form No. 101 (1955)
&222 1 TO DR.
(G Unit) L J
1,2? 6 l3ea c)k &ew On Account of Appropriation No. 7 U U c for 2
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING' NATURE OF BUSINESS AUTO MILES MILEAGE
20 Id Point Point Start Finish TRAVELED PER MILE
G 1
Auto License No. TOTALS $'O
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.
Date
Clam No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as required
by law;
That it is based upon statutory authority; correct
That it is apparently incorrect
On 4 of Appropriation No, for
Disbursing Officer
Allowed 20
in the sum of $t o
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