192687 12/10/2010 CITY OF CARMEL, INDIANA VENDOR: 364930 Page 1 of 1
0 ONE CIVIC SQUARE GARY NELSON CHECK AMOUNT: $200.00
CARMEL, INDIANA 46032 560 CEDAR LAKE COURT
CARMEL IN 46032 CHECK NUMBER: 192687
CHECK DATE: 12/10/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1096 4358400 200.00 REFUND
PASS REFUND RECEIPT
Receipt 545519
Payment Date: 12/06/10
Household 34007
Monon Community Center Gary Nelson Hm Ph: (317)843 -0573
Carmel IN 46032 560 Cedar Lake Court Wk Ph: (317)917 -2741
Carmel IN 46032 Cell Ph: (317)439-4705
Phone: (317)848 -7275 gnelson002 @indy.rr.com
Fed Tax I D #35- 6000972
Pass Details
MEMBERSHIP CHANGE Refund Of 200.00
Pass Holder. Gary Nelson Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: PT1 5x60 min (M PT1560), #102445 50.00 0.00 50.00 0.00 0.00
Valid Dates: 0 3/2 512 0 1 0 to 06/25/2011 Pass Change)
Pass Visit Info: Number of Visits: 5
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 12/06/10 12:54:42 by LWW FEES ADJUSTED ON CHANGED ITEMS 200.00
NET °'AMOUNT FROWCHANGED: ITEMS:f 200t00r_:
T.OTAL=AMOUNT'REFUNDED' 200:00
NEW NET HOUSEHOLD BALANCE 0.00
Refund of =a 200.00 Made By REFUND FINAN With Reference Check
All refunds are subject to State Board of Accounts claim procedure and may take 4 -6 s to process. A check will be
issued. No cash or credit card refunds.
Ull1(�Olr��l, l2. I.o. Zd l
Authorized Signature Date utho ize Signature Date
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Page 1
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.
Nelson, Gary Terms
560 Cedar Lake Court Date Due
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
1216/10 545519 Refund 200.00
Total 200.00
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.
Nelson, Gary Allowed 20
560 Cedar Lake Court
Carmel, IN 46032
In Sum of
200.00
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO, ACCT /TITLE AMOUNT Board Members
Dept
1096 -22 545519 435$400 200.00 1 hereby certify that the attached invoice(s), or
bills) 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
200.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund