166431 11/24/2008 CITY OF CARMEL, INDIANA VENDOR: 00350464 Page 1 of 1
ONE CIVIC SQUARE WESTFIELD PHARMACY CHECK AMOUNT: $100.00
CARMEL, INDIANA 46032 PO BOX 516
„ao WESTFIELDIN 46074 CHECK NUMBER: 166431
CHECK DATE: 11/2412008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
911 4358400 100.00 REFUNDS AWARDS INDE
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WESTFIIELD PHARMACY I T CT 9 STATEMEN 1 Page 1
1C�3'S.UNION, PO BOX 516 I"�Sj F L� Statement Dated Patlen4 Code
WESTFIELD, IN 46074 PHARMACY
317 896 -9378 N�ION STREe 10/31/2008 HAMBDTF
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THIS IS A NEW STATEMENT FORMAT INCLUDING A RETURP2? E.NVAPE FOR YOUR CONVE NIENCE
DPT MED
DATE'
R. NUMBER OTY DESCRIPTION W L OUNT DISCOUNT S TAX, ITEM TOTAL
L COD DED
M 0 PATIENT: HAMILTON BOON
E CO DRUG W60UNT: HANIBDTB, €.�,E�O
10/17/2008 1 FUNERAL ARRN 100.00 .00 .00
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c 't #00413 00,
00 100.00
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MTD Med. Deduction Non Le end forMOnth
100.00
YTD Med. Deduction L end for Montfi:
11/01/2008
Over 30" "''Ove'r`60�.,,,..; .Over.90 Over 120 '':Over,150 ,.:Over180
AMOUNTDU x.
Previous Balance Char es This Moii*lFA Fini'rice Chares TOTAL CHARGES' I Pa rnents &"Crcedns ll 100.00
1 100.00 +1 100.00
QSIA4WSE WSTFIELI P VF4 95947QS1 1727 11032008142402 23 9
Prescrib;Aly 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, nYmbei -of units, price per unit, etc.
I Payee
it iad //k0LA__"4 C4- Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
/013 /oF G�- �c.a.L p„tti y y�L� -IJZ CAUL
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
Ij IN SUM OF
G��° �a 0 7
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
gip`/- oo /00 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 oP
ignature
MA -T 9,<-
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund