166192 11/24/2008 CITY OF CARMEL, INDIANA VENDOR: T362197 Page 1 of 1
ONE CIVIC SQUARE CHERYL ELKO
i CHECK AMOUNT: $312.50
CARMEL, INDIANA 46032 35 ROSEWALK CIRCLE 2 H
CARMELIN 46032 CHECK NUMBER: 166192
CHECK DATE: 11/24/2008
DEPARTMENT ACCOUNT PO NU MBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 312.50 OTHER EXPENSES
Date: 11/12/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
A T H I S FOP t
Bill To: CHERYL L ELKO Ica -9: 78652 7241 9100 E8130
35 ROSEWALK CIRCLE APT 2H
CARMEL, IN 46032
From: 131ST ST HAWTHORNS DR
To'. ST, VINCENTS HOSPITAL CARMEL
ANTHEM BC /BS/ 37010
Patient: CHERYL L ELKO YRP702M56678
35 ROSEWALK CIRCLE APT 2H Insurance
CARMEL, IN 46032- 2
Patient No: 200802270
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
$312.50 $625.00 312.50
CPT
Date Description Char es Credits
09/17/2008 BASIC LIFE SUPP— EMERGENCY A0429 $360.00
09/17/2008 MILEAGE A0425 $12.50
10/28/2008 PAYMENT $312.50
11/07/2008 COMMERCIAL INSURANCE PAYMENT $312.50
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 11/12/2008:
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
K R
Bill To: CHERYL L ELKO ICD -9: 78652 7241 9100 E8130
35 ROSEWALK CIRCLE APT 2H
CARMEL, IN 46032
From: 131ST ST HAWTHORNE DR
To: ST. VINCENTS HOSPITAL CARMEL
1 ANTHEM BC /BS/ 37010
Patient: CHERYL L ELKO YRP702M56678
35 ROSEWALK CIRCLE APT 2H Insurance
CARMEL, IN 46032- 2
Patient No: 200802270
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
$312.50 $312.50 $0.00
CPT
Date Desciiptiom Charges Credits
09/17/2008 BASIC LIFE SUP EMERGENCY A0429 $300.00
09/17/2008 MILEAGE A0425 $12.50
10/28/2008 PAYMENT $312.50
11/07/2008 COMMERCIAL INSURANCE PAYMENT $312.50
11/12/2008 REFUND 312.50
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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35 R05EWALK CIRCLE 2H
CARMEL;', IN 46032- 2570 DATE V 7a1. C (5 v
PAY TO THE Sw
ORDER OF
E ..DOLLARS ea8= <I.
kY
EYBANK NATIONAL ASSOCIATION
1"" INDIANAPOLIS INDIANA 46204
1 800 KEY2YOl! j
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F 'FOR D 12A K
PRINTED ONRECYCLED PAPS %USkNO VEDETABLEDASE91NK5
CLAIM NO 14- 2262 -057 POLICY ND 4043 893 -14H LOSS DATE 09 -17 -2008 PAYMENT NO 1 18 066575 .1
nCov ®�a a Descr.� tion> pmounG COL: Pa 'Cd DATE 11 -02 -2008
MEDICAL PAYMENT $312.50 600 2 AMOUNT $312.50
T I N 14 3560009'12
REMARKS 9/17/2008
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 066575 J
WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441
INSLL•MCI� MPC INDIANA 18 -501 L025 COLUMBUS, OH
11-02-2008
CLAIM NO 14 -2262 -057 I NSURED ELKO, CHERYL DATE mm i) o Y Y Y Y
e:_
"F..
LOSS DATE 09 -17 -2008 ON BEHALF OF CHERYL L. ELKO
*EXACTLY THREE HUNDRED TWELVE AND 501100=,DOLLARS *312.50
Pay to the
Order of: CARMEL FIRE DEPT
2 CIVIC SO
CARMEL IN 46032 -2584`
TT
N BY
ll NOv t 7 2009
CLAIM NO 14 -2262 -057 POLICY N4 4043- 893 -14H LOSS DATE 09 -17 -2008 PAYMENT NO 1 18 066575 J
Coves a Descr i tion' Amount COL Pa Cd DATE 1 1 20
MEDICAL PAYMENT $312.50 600 2 AMOUNT S312.50
TIN 14- 35600097-
REMARKS 9/17/2008
0
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY l8 0,66575
WEST LAFAYETTE; IN JPMDRGAN_CHASE:BANK,,NA ,56.1544/441
wj
COLUMBUS, DH
`:MPC INDIANA '18-15011, -L025
F
CLAIM No :'14 2262 05'7 INSURED EL "KO,' °CHERYL aArl
LOSS DATE,` 09 -17, -2008 ON BEHALF "'OF CHERYC-L. ELKO
'EXACTLY THREE HUNDRED TWELVE AND 501100 DOLLARS
Past to the
Order of: CARMEL FIRE DEPT
2 CIVIC SO
CARMEL IN 46032 -2584
AUTHORIZED SIGNATUR
c
f
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 f
l' f I X Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
JG C s
Qn
Total 0
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 C/
q6 C
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
-NO 2 4 240a
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund