192617 12/10/2010 CITY OF CARMEL, INDIANA VENDOR: 358408 Page 1 of 1
r ONE CIVIC SQUARE TIFFANY BUCKINGHAM
CARMEL, INDIANA 46032 5130 PRIMROSE AVE CHECK AMOUNT: $122.18
INDIANAPOLIS IN 46205
CHECK NUMBER: 192617
CHECK DATE: 1211012010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NU MBER AMOUNT DESCRIPTION
1081 4239039 17.18 GENERAL PROGRAM SUPPL
1081 4343000 105.00 TRAVEL FEES EXPENSE
PaESCRIB ED BY STATE BOARD Or ACCOUNTS rr MILEAGE CLAIM GENERAL FOAM NO. 121 (1986)
�c X52 TO i av�4 yC,1 VA
(GOVERNMENT IT) ON ACCOUNT OF APPROPRIATION NO. FOR
(Oi7(Cr, SOAAD, DFlAA O�
SPEEDOMETER
DAT FROM TO I READING AUTO MILEAGE
NATURE OF BUSINESS IAILFS 4S SD C
Za L POINT POINT START FINISH TRAVELED PER MILE
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2 j t_-
nG 1 J 10v i N�OY
G` I G mil •�o mss
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U
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2 C av�
Gr -e.
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AUTO LICENSE NO. TOTALS 2-)D 4 45
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 1.55, Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, ter aliowing all just credits
end that no part of the same has been paid.
Date
�Sq
NOV
Ye
Carmelo Clay
Parks &Recreation
Employee Expense Reimbursement Request
Date of Fund Account Account
Receipt Vendor listed on receipt Line Budget Description Amount j Purpose o f Expense
All receipts should be attached in the same order as listed above.
No sales tax will be reimbursed. TOTAL:
Employee Name I Q 11'JCk
Address jt30 ne e &Ye NOV' 2 9 2010
Check
payable to: City, St, Zip
Signature: Approved by:
Date: —22 —t 0 Date: -c)a
Business Services Division, Revised 7 -7 -08
FILE: Shared \Administrative\Forms\staff FormslEmployee Exp Reimb Request
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.
358408 Buckingham, Tiffany Terms
5130 Primrose Ave
Indianapolis, IN 46205
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
11/17110 Reimb. Mileage 10/11 11/17/10 105.00
11/15/10 Reimb. Program supplies 17.18
Total 122.18
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.
358408 Buckingham, Tiffany Allowed 20
5130 Primrose Ave
Indianapolis, IN 46205
In Sum of
122.18
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO# or INVOICE NO. ACCT #[TITLE AMOUNT Board Members
Dept
1081 -2 Reimb. 4343000 105.00 1 hereby certify that the attached invoice(s), or
1081 -2 Reimb. 4239039 17.18 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
9 -Dec 2010
Signature
122.18 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund