156049 02/05/2008 ,a a CITY OF CARMEL, INDIANA VENDOR: 359957 Page 1 of 1
ONE CIVIC SQUARE BLOCKOMS GOLF MANAGEMENT CO LLC
CARMEL, INDIANA 46032 7033 SEA OATS LANE CHECK AMOUNT: $637.55
INDIANAPOLIS IN 46250 CHECK NUMBER: 156049
CHECK DATE: 2/5/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE N AMOUNT DESCRIPTION
905 4347500 637.55 GENERAL INSURANCE
i•
I
A F und
INSURED COPY
W0 70 SURANCE COMPANY OF AMERICA Invoice Date 01/22/2008
BOX 77000 DEPT 77125
DETROIT MI 48277-0125
t
Insured: Agent:
BLOCKOMS GOLF MANAGEMENT CO, WALKER ASSOCIATES INSURANCE
LLC PO BOX 19445
7033 SEA OATS LN INDIANAPOLIS IN 46219 -0445
INDIANAPOLIS IN 46250A 131 E
1111111111F1111llllllllllllllll H 1111111111111111111 lllllllllllllllllllllllllllllllllllllllllllll [111111
Policy Number: WCV 6033567 00 01 Telephone: 317- 353 -8000
Effective Date: 07/21/2007
Expiration Date: 07/21/2008
For billing questions please call 1- 877 -563 -4636
x. 1014
BLOCKOMS GOLF MANAGEMENT CO. 6
DATA o l 30 S
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PAYMENT DUE 02/21/2008
PAYMENT MUST BE RECEIVED ON OR BEFORE DUE DATE TO AVOID CANCELLATION
DETACH ALONG THIS PERFORATION
TO ENSURE PROPER PAYMENT POSTING, PLEASE SEND REMITTANCE SLIP WITH PAYMENT
Thank you for your prompt payment.
Policy Number WCV 6033567 00 01 0015185
Effective Date: 07/21/2007
Amount Due Now: $637.55
Check Number 1011
(Please write check number in the space provided)
Insured: Please Remit Payment to:
BLOCKOMS GOLF MANAGEMENT CO, ACCIDENT FUND o
LLC PO BOX 77000 DEPT 77125 0
7033 SEA OATS LN 0000000641 DETROIT MI 48277 -0125
INDIANAPOLIS IN 462504131 F I
'1 1111111111111111111�111111111111111111111111111111 111U1111111111111111111111111111 111
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.
r
d Payee
i
Purchase Order No.
z
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
1-3 v 4� 3 75 S
Goer!
Total '�o
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.
ALLOWED 20
359957 IN SUM OF
Blockoms Golf Mgmt LLC
7033 Sea Oats Ln
Indianapolis IN 46250 -4131
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or
D PT. INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify that the attached invoice(s), or
(�f- e 7S 3 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
1-3 20 0Z
ign ure
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund