162634 08/20/2008 -u, CITY OF CARMEL, INDIANA VENDOR: T361702 Page 1 of 1
ONE CIVIC SQUARE SWAMINATHAN ARIYUR
s CHECK AMOUNT: $306.25
CARMEL, INDIANA 46032 5651 AQUAMARINE DR
CARMEL IN 46033 CHECK NUMBER: 162634
CHECK DATE: 8/20/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 306.25 REFUND
jj
I
291 NATIONAL CASUALTY COMPANY
P.O.BOX 420
Springfield, MA 01101
1- 413 306 -6041 EXPLANATION OF BENEFITS;
Date 07/25/2008
Page 2
EOB No: 0807252623
CARMEL FIRE DEPARTMENT Group NCCORE NCCORE
2 CIVIC SQUARE EOB No. 0807252623
CARMEL IN 46032
Attn: CARMEL FIRE DEPARTMENT
RECEVED AUG 5 200j
eo s e e -e e e a e• a
NATIONAL CASUALTY COMPANY` BANK.OF.AMERICA 04.7569
Ad d by Administered b
Consolidated Health Plans CONSOLIDATED; HEALTH PLANS,
F
70
r
07 /25/2008
PAY TFIREEH, ND
RED AND 2' 5 /1�0. DOLLARS
FO,R 0807252623
4
'CARMEL FIRE DEPARTMENT
2 CI�7I C SQUARE
CARMEL, IN 46032
S
SIGNATURE HAS A COL O RED BACKGROUND BORDER CONT MI CR O PRINTi NG
n°04756911 1:07b9212841: 8 76 501 646011'
CHASE C P
CHASE ONLINE BILL PAYMENT
PO.BOX 260169
BATON ROUGE LA 70826 -0169
July 18, 2008
24009 BPC 001 001 08200 87843244 101`1 a
CARMEL FIRE DEPARTMENT
Emergency Med Svcs
2 Civic Square
Carmel IN 46032 -7543
r
APPLY TO ACCT Aditya Ariyur 200801277
SWAMINATHAN R.ARIYUR
5651 AQUAMARINE DR
CARMEL IN 46033
$306.25
Ariyur Patient No 200801277
JOB
JIB X:e'.a �0 8 �eE.i Java. V
PLEASE POST THISTAYNIENT FOR'OUR 1`IU7�JAL CUSTOMER
5306.25
CHASE ONLINE BILL PAYMENT APPLY TO AC Aditya A:riyur ..200801277 87843244
PO'13012601G9 S�Vr�N1INATILAN RRIYUR`: 25- 3!440
BATON :ROUC E LA :70826` -0169 5651 AQUAMARINE DR
(800) 472-6236 C 4RNiLL IN 46033 Ju13 2008
Uhl $306.25
CHASE
Pa y THREE HUNDRED SIX AND 257100 DOLLARS
To CARMEL FIRE DEPARTNIENT Check Void After 90 Days
the .:Lmei'ceney Med Svcs
Order -2 Civic.Squarc
f
of CarmcPIl\' 46032 -7543 0
JPMorgan Chase, NA Columbus, OH'43240
11 24411' 1:0440000371: 6585330 10 311°
Date: 08/11/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
'k"OUt
Bill To: SWAMI NATHAN R ARIYUR ICD -9: 8730 7840 7804 E8888
5651 AQUA MARINE DRIVE
CARMEL, IN 46033
From: 1402 W MAIN ST
To: ST. VINCENT CARMEL
1 ANTHEM BC /BS/ 37010
Patient: ADITYA ARIYUR YRP263M57512
5651 AQUA MARINE DRIVE Insurance
CARMEL, IN 46033- 2
Patient No: 200801277
WE DO NOT FILE CLAIMS FOR YOUR INSURANCE. THIS INVOICE IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW.
THANK YOU.
Total Amount Total Paid Balance
$306.25 $612.50 306.25
CPT
Date Description Charges Credits
05/19/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
05/19/2008 MILEAGE A0425 $6.25
07/25/2008 PAYMENT $306.25
08/05/2008 COMMERCIAL INSURANCE PAYMENT $306.25
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 08/11/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
ry 6 'awl' $saw n: 1 4 ''ee i 'k. i
Bill To: SWAMI NATHAN R ARIYUR ICD -9: 8730 7840 7804 E8888
5651 AQUA MARINE DRIVE
CARMEL, IN 46033
From: 1402 W MAIN ST
To: ST. VINCENT CARMEL
I ANTHEM BC /BS/ 37010
Patient: ADITYA ARIYUR YRP263M57512
5651 AQUA MARINE DRIVE Insurance
CARMEL, IN 46033- 2
Patient No: 200801277
WE DO NOT FILE CLAIMS FOR YOUR INSURANCE. THIS INVOICE IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW.
THANK YOU.
Total Amount Total Paid Balance
$306.25 $306.25 $0.00
CPT
Date Description Charges Credits
05/19/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
05/19/2008 MILEAGE A0425 $6.25
07/25/2008 PAYMENT $306.25
08/05/2008 COMMERCIAL INSURANCE PAYMENT $306.25
08/11/2008 REFUND 306.25
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
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.
l n /Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
b s 6' Y P
Dn A OU l� i' U-�
s
x
Total
e
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
�L(/Q/7�if7 LL�I� IN SUM OF o�O.
�a ZI1e0 3
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
20c
Sig ature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund