193122 12/22/2010 CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
0 ONE CIVIC SQUARE HINCKLEY SPRINGS CHECK AMOUNT: $25.57
CARMEL, INDIANA 46032 PO BOX 660579
DALLAS TX 75266 -0579 CHECK NUMBER: 193122
CHECK DATE: 12/2212010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4239099 2677859 25.57 OTHER MISCELLANOUS
1- 800 -4- WATERS 492 -8377 www.HinckleySprings.com
Upcoming Delivery Dates Hi
December January February SpringsG B ottled Water Filtration Coffee
Thursday, 23 Thursday, 6 Thursday, 3
Thursday, 20 Thursday, 17 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: 12 -11 -10
CARMEL CITY COURT Invoice 2677859 121110
1 CIVIC SQ
CARMEL, IN 46032 Purchase Order
Date Transaction Details Qty. Each Amount
Previous Balance 35.50
Payment 0.00
Remaining Balance 35.50
R103202494748 WHITE HOT AND COLD COOLER RENTAL 1.0 13.50 13.50
12 -09 -10 T103433042006 HINCKLEY SPRINGS 5G DRINK NON -SPILL 1.0 9.99 9.99
5.0 GAL BOTTLE RETURN -1.0 6.00 -6.00
5.0 GAL BOTTLE DEPOSIT 1.0 6.00 6.00
Rec'd By: Not Available or Refused
12 -09 -10 58798702 ENERGY SURCHARGE 1.0 2.08 2.08
Total New Charges 25.57
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, a our bill and much more. Log on today!
30356 -P -0034
Pr� Bal Payment Total New Charges :Pa�yThis Amount
$0.00 $25.57 $61.07
Write the complete account number on your check. Detach remittance and mail with payment in the enclosed envelope. To pay online go to www.HinckleySprings.corn
How to Read Your Statement Important Monthly Promotions:
_Opc °min9 °•es ion We Deliver! Register online for access to your
June 3009 h1 W9 Au9u,t 3009 b.,'�
Delivery Calendar: M�a,e �s��,x.�ofv account. You can view and pay your bill,
Me�.33 Maw, o I �s; t; s�„ ��A check delivery schedu' and order
Your scheduled deliveries for
the next three months. u�.• 3 products all online.
Customer Account Number:
For prompt service, please use this Bottle Deposits:
number when referring to your account. o o� Highlights bottle deposits and returns.
oW 81. Easy to Pay:
Pay your invoice through the mail, online at
Summary: 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. Please detach remittance and mail
a-❑ wR s l I r I I t using business envelope provided.
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Important Monthly Message s ,,,u,.,.,,u
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 your letter, give us the following information: OPT OUT NOTICE: If you do not wish to participate in this check conversion
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
b w
Purchase Order No.
Terms
/to i Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
5 5 7
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
o _57 :7
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PQ# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
p�G�'775 I r. a J 7 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
5,
20
i r
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund