No preview available
HomeMy WebLinkAbout166192 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 nsk? L�3S��' uP�': �..1; nc5tSt1 YYFF�? 7T' t?�3.C �.RitYS'L�➢1t'RL n °�iS�Tmy; 1�FICi� "N^ +s?T rtvsil� '3� d h I 2aloa0a0 24 7 rf p[ CHERYL L..ako f, 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 L' l 4• is 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