197162 05/11/2011 CITY OF CARMEL, INDIANA VENDOR: 365282 Page 1 of 1
0 ONE CIVIC SQUARE ERIE INSURANCE
CARMEL, INDIANA 46032 PO Box 9326 CHECK AMOUNT: $100.00
FT WAYNE IN 46899
CHECK NUMBER: 197162
CHECK DATE: 5/11/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 100.00 OTHER EXPENSES
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[BE] I D ED 0
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'CITY O CARMEL
JAMES MmNARD, MAYOR
May 6,201!
Erie Insurance
P.O. Box 9326
Ft. Wayne, IN 46899
RE: James Spurling/Claim #062010610221045 DOS 01/22/2011
Dear Sir /Madam:
Enclosed you will find a reimbursement check in the amount of $100.00. On April 21,
2011 we received a check from you in the amount of $638.08 for Mr. Spurling's
ambulance transport on January 22, 2011. Since the amount of the invoice was $538.08,
we are issuing you a refund of $100.00. If you have any questions, please feel free to
contact me at (317) 571 -2605.
Sincerely,
Becky S. an 4
Billing Administrator
CARNIn, Fim, DEPARTMENT
STEVEN A. CouTs HEADQUARTERS
Two CIVIC SQUARE, CANUMEL, IN 46032 OFFICE 317.5712600, FAx 317.571.2615
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
An invoice or bill to be property 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.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
b S O o
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
r� 1 e
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), 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
c
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund