157827 03/31/2008 CITY OF CARMEL, INDIANA VENDOR: 359957 Page 1 of 1
ONE CIVIC SQUARE BLOCKOMS GOLF MANAGEMENT CO LLC
li GHECK AMOUNT: $637.55
CARMEL, INDIANA 46032 7033 SEA OATS LANE
INDIANAPOLIS IN 46250 CHECK NUMBER: 157827
CHECK DATE: 3/31/2008
DF-PA RTMENT ACCOUNT PO NUMBER INVOIC NUMBER AM OUNT DESCRIPTION
905 4347500 637.55 GENERAL INSURANCE
INSURED COPY
�Accpdent Fund
INSURANCE COMPANY OF AMERICA In voice Date 03/23/2008
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
1I1II11 111111 11111111 11111111111111111111111111 i11111111111111111111111t1111111111111111111111 L J
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
may.
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BLOCKOMS GOLF MANAGEMENT CO.
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1! 1 f; V1 U v C3 PAS 631. SS
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FOR
PAYMENT DUE 04/21/2008
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 o
LLC PO BOX 77000 DEPT 77125
7033 SEA OATS LN 0000000915 DETROIT MI 48277 -0125
INDIANAPOLIS IN 4625011131
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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
`�vhom,"rates per day, number -of hours, rate per hour, number of units, price per unit, etc.
Payee
t.f-o: Purchase Order No.
C—aoc fr GU4.b Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
t o 10( VVk hA5Q Vw+ -tcQ IP 6 5 T S3
Total
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.
r ALLOWED 20
IN SUM OF
j &kom6 &ouf: kk Ptol ne KAe�
w
ON ACCOUNT OF APPROPRIATION FOR
C" eve, 6
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUN
DEPT. T
I hereby certify that the attached invoice(s), or
GI,L� 631 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
.2a
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund