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164623 10/16/2008 CITY OF CARMEL, INDIANA VENDOR: 362002 Page 1 of 1 s O w 1 ONE CIVIC SQUARE LLOYD B C EUGENE BROWN TRUST CARMEL, INDIANA 46032 PO Box 130 CHECK AMOUNT: $244.84 GREENVILLE OH 45331 CHECK NUMBER: 164623 CHECK DATE: 10/16/2008 D EPART MENT AC PO NUM BER INVOICE NUMBE AMO DESCRI 102 5023990 244.84 AMBULANCE REFUND etna E PA,., T110 98 CLAIM PA YMENT Please Retain for Future Reference 023978 J]K2PJA 067b99 (1) MEDICAL DOCTOR MD /PVN: 2260490 flUE STION S: 1 800 624 0756 DATE PRINTED: os /1612008 CITY OF CARMEL FIRE DEPT. Page 1 of 2 (1) 2 CIVIC SQUARE CARMEL IN 46032 -7543 �t�n�t��ttl�ttrrt��trt�t�ltrt�r�rltt�it�rl��r��rnrr�tlt�rt�� TIN. Check Number 3682673.1. Check Amount J $903:59' POS SPECIALIST RECEiVE-D SEP 2 6 2008 Member Name Nlember Nnmher Nlenlher 1m nice. IMS Units Procedure NIQ1)S 1011ed Responsibility Paid N'lessage(.$) PAYMENT 01 CL.AINtS PR(.)VFI)1 R NAME,: CITY OF CART IFT. FIRF" 171?PT. Pk(_)VIDFR NUMIIJ?R: 226049(1 C: L. BROWN Cv E13CXQ,%V POS 2(70801387 610 1 AM 1.00 A0429 1`111 $300.00 $59.95 5230.84 PF5 1 200801387 h /01 /OS 1.00 A0425 11 $625 $+1.25 `5.00 PFS 1 CLAIM WAS Rf ;,('Vl') ON 9 10,5/08 IT )TA L- 5244.84 M C?N1NR08 7L ..7 M. ti Aetn ©Hanlih'Mnmgemrnt heCk N 'LL .o 3682673;1 J o sox sa +i 07 Acct C El PASO rx 78880 1�a� N 260490 B 38834756 'cam,rF d: .4;'n a �V4 }2 u r q1, ..,g 1¶I� y 'i� :tlih l� IL'4' I.. IhS,IlS P 0 t i sx �'11�� .'Irr 4'.F-,l 1 li�i .i iii W ,I r r t w .tr 5x rr.,. F zi'�'t 1 4114,:•. •F `�,ViAI .,a'Il l s i l l j'��P I, r 7 Yq r `t; Y a A r i J l "gr�MV'. IS�N tl 1w s-. ses� _1 4" 69'i 8 =2008 �1 I i r ,,7b', '.r �r :I�i Ire a r`'i�� P 11 si RS AND i 4 G 1 I r NE�, ",UNL1 'ED rHREE�DOL•LA 59/10.0 t, ��pp ,i�„ ti 6 V" r'',gg 11 fi�d 1W�A. 3 1 1:i 110 )11 40 ti s.;r 1�'o Yn p 1 iMl :'f:. ni 4 u se 41' M v1 �y •c 1 4 i 4 Via •r�`t- 7 vt' �4 �l', tlJ' .�tl "1')�" „rN�� it w�i "V t r r u'tlrA a �1, 91 r tfIl3AF�ER G�NrE;1kLAR TO THE CITY D CARME oanpio 20IVICSC2IAR< ry hl )r _s $9 CPRM 'I IN 48032 I� I 9 a g r tlk x 5.: 'q a J r"'i, �,y 7��+I�I�ry�fry� I��FlN 9 h'7 Iy d r a `n a ��:.,x7�' ��ar4 /lc a.;, a w °yn19'N" S. itr5 C ��1. V' Plfi. 'P4P i �bn i li ioy :'a .t �tll a "ly1`tIJ, k �I,, {dlb e 7esltaort R 'ry�; F ti.. a t •f�gfi p k -;t +'Sbf 1 V 11, i,� I� df(�44 :.ii j 1 q'�I• I 0. 1 11 1 1'., II s, 'r 11hx I 11' )R�l �I f G P °'O qq 14 at, !4Y Cl r a v Q1µ �Ia IB' I� s tltlm i1 0368 273'L:. .03`1.L:0,0 2091. 3:8.84 75611° f THIS CHECK IS BLUE AND THE�PAPER HAS COL AND A WATERMARK. PAAK NATIONAL BANK °Second National Bank I r NE wAFIK OFItO 43055 x Dtvls�on of`ThetPark NaUonai Bank r r Greenville OH`45331 r r f :i G067 Lloyd B C`Eugerna Brown Trust Ma n :Agy s PAY Three Mundred Six Dollars 251100 TO THE 09/26/08 $30fi O5 NT ORDER OF Carmel Fire Departme c 2 Civic Square TRUST DEPARTM nt ENT HEC 90 K VOID AFTER DAYS IF NOT CASHED Carrn6 IN 46032 t: v c 4 y a bJ AVTHORIEED SIGICAT�fRE .7 ,f� � 4 f i' .f a"` N n ks ..s k'.'. .;.d .n Sb n.i. P. .tk'. A..7 518519 Second National Bank I G067 Lloyd B C Eugenia Brown Trust Man Agy Carmel Fire Department 09/26/08 2 Civic Square Carmel IN 46032 $306.25 14298624 Md,Dds, Nurse, Nursing Home,Hosp Basic Life Supp- Emergency i Division of The Park National Bank Date: 10/03/008 CARMEL FIRE DEPARTMENT EMERGENCY VIED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ►D# 356000972 Bill To: CLARA E BROWN ICD -9: 7245 E8888 1768 SPRUCE DR CARMEL, IN 46033 From: 12999 N PENNSYLVANIA ST To: CLARIAN NORTH 1 AETNA LIFE INSURANCE Patient: CLARA E BROWN MEBCXQXV P. O. BOX 130 Insurance GREENFIELD, OH 45331- 2 Patient No: 200801387 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU, Total Amount Total Paid Balance $306.25 $551.09 244.84 CPT Date Description Charges Credits 06/01/2008 BASIC LIFE SUPP— EMERGENCY A0429 $300.00 06/01/2008 MILEAGE A0425 $6.25 09/26/2008 COMMERCIAL INSURANCE PAYMENT $244.84 09/30/2008 PAYMENT $306.25 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 10/03/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: CLARA E BROWN ICD -9: 7245 E8888 1768 SPRUCE DR CARMEL, IN 46033 From: 12999 N PENNSYLVANIA ST To: CLARIAN NORTH 1 AETNA LIFE INSURANCE Patient: CLARA E BROWN MEBCXQXV P. O. BOX 130 Insurance GREENFIELD, OH 45331- 2 Patient No: 200801387 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT 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 06/01/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 06/01/2008 MILEAGE A0425 $6.25 09/26/2008 COMMERCIAL INSURANCE PAYMENT $244.84 09/30/2008 PAYMENT $306.25 10/03/2008 REFUND 244.84 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. Payee I n W o rLf q eA Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) C mb s r 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 IN SUM OF �7 a a �Ll 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 PCT J 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund