HomeMy WebLinkAbout199007 07/06/2011 CITY OF CARMEL, INDIANA VENDOR: 363862 Page 1 of 1
ONE CIVIC SQUARE JASON FORCE
CARMEL, INDIANA 46032 30 SLEEPY HOLLOW COURT CHECK AMOUNT: $686.40
WESTFIELD IN 46074 CHECK NUMBER: 199007
CHECK DATE: 7/6/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 06.30.11 AAC 686.40 OTHER EXPENSES
C ITY OF CARMEL $b
ADOPTION ASSISTANCE CLAIMI FORM 30I t
SEE REVERSE SIDE FOR INFORMATION AND INSTRUCTIONS
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Employee Name (First MI Last): -t—o� S �RlE
Department: �r ?F 1 p �7
Social Security Number:
Home Phone: 3 1 j y/:� 0
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Child's Name: 51 E�� A So.1Fi��,S'O�/ Date of Birth:
SSN (if known): � Final Adoption Date: r8,q
Attach copy of adoption decree if adoption has been finalized.
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Date: D Paid To: Serv Rendered: Amount.
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Attach original itemized receipts in U.S. dollars for all expenses listed above. No reimbursement will be made without appropriate documentation.
Attach separate sheet of paper for additional expenses.
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I hereby request reimbursement for the adoption expenses listed above. By signing below, I certify that:
Check appropriate box: The child identified above has been placed in my home pursuant to adoption X, or
The adoption of the child identified above has been finalized and
To the best of my knowledge, each expense listed above is a qualified adoption expense under the City of Carmel
Adoption Assistance Program; and
All statements and documentation relating to this claim are true and complete.
I understand that incomplete or inaccurate information may adversely affect my eligibility for benefits through the
Adoption Assistance Program.
Employee Signature: Date:
Form HR103 (1108) Official form cannot be altered or substituted.
3500 DePaUW Boulevard 317- 334 -17 18 wwv✓ k dspeace org
Pyramids Building ii2 317 -334 -1712 Fax
www.fostercare com
Suite 2071
Indianapolis, IN 46268 -6116
KidsPeaceo
ADOPTION PREPARATION SUMMARY
FAMILY INFORMATION:
Applicant A Applicant B
Name: Jason Force Melissa Force
Date of Birth:
Race: Caucasian Caucasian
Soc. Sec.
Occupation: Maintenance Tech. Homemaker
Address: 30 Sleepy Hollow Ct.
Westfield, IN 46074
Phone: 317 -417 -0146
CHILDREN IN THE HOME:
Name Date of Birth:
Spencer Force
(subject of adoption)
DATES OF CONTACT:
05/24/20.1
Leslie Spangle 135 0 Date
Family Resource Specialist
Lk 1
3o 1 Reinke A, LM C Date
Program Manager
7
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
Jason Force
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
06/30/11 06.30.11 AACF Adoption Assistance Claim
I
Total
1 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
I
VOUCHER NO. 06130/1 WARRANT NO.
Jason Force ALLOWED 20
IN SUM OF
Employee
$6860
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
0 bill(s) is (are) true and correct and that the
cF 301 0o materials or services itemized thereon for
which charge is made were ordered and
received except
20
f Signatu
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund