163454 09/03/2008 CITY OF CARMEL, INDIANA VENDOR: T361784 Page 1 of 1
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ONE CIVIC SQUARE WENDY WHITT CHECK AMOUNT: $20.00
CARMEL, INDIANA 46032 3732 BARRINGTON DR
CARMEL IN 46033 CHECK NUMBER: 163454
CHECK DATE: 9/3/2008
DEPARTMENT ACC PO NUMBER INVOICE NUMB AMOUNT DESCRIPTION
102 5023990 20.00 OTHER EXPENSES
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THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND -NOT A WHITE BACKGROUND.
13079 y�
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TRICARE Payment 433
PNC Bank, National Association N 08 -62687758
JEANNETTE, PA TRICARE North Region
P.O. Box 870141
DATE Health Net Surfeide Beach, SC 29587.9741 T R I C A R E AMOUNT
1 (877)874.2273.
'Federal Services
08 -13 -08 MCS810 Noffh 03ZECOMM Co
356000972
CASHIER
PAY TO THE ORDER OF
For your protection, ro
require two IDs from payee.
CARMEL 'FIRE DEPT AMBULANC
2 'CIVIC .SQUARE.
CARMEL IN 46032 -2584
VOID 120 DAYS FROM DATE OF ISSUE 898850 013079 AS TREASURER
11'6 268 7 7 5811' 1:0433016271: LO 1926475611'
CHECK NUMBER
ANTHEM INSURANCE COMPANIES FEP FIFTH THIRD BK OF NORTHERN KY z
At1't�lelll DBA ANTHEM BLUE CROSS AND BLUE SHIELD 0041828766
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7121 9354
CHARLES L. OR WENDY S. WHI'rr
(SGM USA /RET) 60191988
3732 BARRINGTON DR. 843 -2412
DATE
CARMEL, IN 46033 -3815
PAY TO TH
N ORDER OF
DOLLARS L�J
is
to
Nafidm City®
MEMO
.1:074000065 1 60 19 198811 93
Date: 08/20/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
C N s FV 9 S 3T 0 RY
Bill To: WENDY WHITT ICD -9: 78609 7806 78652 7804
3732 BARRINGTON DR
CARMEL, IN 46033
From: 3732 BARRINGTON DR
To: ST. VINCENT CARMEL
ANTHEM BC /BS/ 37010
Patient: WENDY WHITT R59112705
3732 BARRINGTON DR Insurance
CARMEL, IN 46033 2 HEALTHNET FEDERAL
Patient No: 200800811 506428241
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$331.25 $331.25 $0.00
CPT
Date Z escettiori Charges Credits
03/23/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
03/23/2008 MILEAGE A0425 $31.25
05/20/2008 PAYMENT $20.00
06/24/2008 BLUE SHIELD PAYMENT $281.25
08/19/2008 COMMERCIAL INSURANCE PAYMENT $50.00
08/20/2008 REFUND -20.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 08/20/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
ACCOUNT ORY
Bill To: WENDY WHITT ICD -9: 78609 7806 78652 7804
3732 BARRINGTON DR
CARMEL, IN 46033
From: 3732 BARRINGTON DR
To: ST. VINCENT CARMEL
ANTHEM BC /BS/ 37010
Patient. WENDY WHITT R59112705
3732 BARRINGTON DR Insurance
CARMEL, IN 46033 2 HEALTHNET FEDERAL
Patient No: 200800811 506428241
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$331.25 $35125 -20.00
CPT
Date Description Charges Credits
03/23/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
03/23/2008 MILEAGE A0425 $31.25
05/20/2008 PAYMENT $20.00
06/24/2008 BLUE SHIELD PAYMENT $281.25
08/19/2008 COMMERCIAL INSURANCE PAYMENT $50.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4-eym&At!z�
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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
VO;ICHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF ego
3
ON ACCOUNT OF APPROPRIATION FOR
41
dcc/Q�
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
UG 2 9 2008 2Q
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund