157293 03/11/2008 CITY OF CARMEL, INDIANA VENDOR: 359957_ Page 1 of 1
ONE CIVIC SQUARE BLOCKOMS GOLF MANAGEMENT CO L 6ECK AMOUNT: $637.55
a`� 1 CARMEL, INDIANA 46032 7033 SEA OATS LANE
INDIANAPOLIS IN 46250 CHECK NUMBER: 157293
CHECK DATE: 3/11/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
905 4347500 637.55 GENERAL INSURANCE
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INSURANCE COMPANY OF AMERICA Invoice Date 02/20/2008
PO BOX 77000 DEPT 77125
DETROIT MI 48277 -0125
Insured: Agent:
BLOCKOMS GOLF MANAGEMENT CO, WALKER ASSOCIATES INSURANCE
LLC PO BOX 19445
7033 SEA OATS LN INDIANAPOLIS IN 46219 -0445
INDIANAPOLIS IN 46250-4131
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Policy Number: WCv 6033567 00 01 Telephone: 317 353 -8000
Effective Date: 07/21 /2007
Expiration Date: 07/21/2008
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BLOCKOMS GOLF MANAGEMENT CO.
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Totals $6,391.00 $5,115.90 $637.55
PAYMENT DUE 03/21/2008
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
(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 0000000498 DETROIT MI 48277 -0125
INDIANAPOLIS IN 46250 -4131
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Prescripediby State Board of Accu 's City Form No. 201 (Rev. 1995
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
d
An invoice or bill to be properly: itemized must show: kind of service, where performed, dates service rendered, by
whom, per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
bl�/lS y0�- u�tav� "eM'elA Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
03 _a3- 1 ✓16 u v &rn U Pa b 3? S
Total 631.5
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
t�1oc,�oS �O IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR.,
G q o s
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
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund