163878 09/17/2008 CITY OF CARMEL, INDIANA VENDOR: 360487 Page. 1 of 1
0 ONE CIVIC SQUARE CARLA NEWCOMER
CARMEL, INDIANA 46032 8991 SHEBURNE WAY CHECK AMOUNT: $54.13
ZIONSVILLE IN 46077
CHECK NUMBER: 163878
CHECK DATE: 9/1712008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
X180 4343004 54.13 TRAVEL PER DIEMS
i
4
PRESCRIBED BY STATE BOARD OF ACCOUNTS
GENERAL FOAM NO. 101 (1986)
MILEAGE CLAIM
TO �/�J Yom'✓
(GOVERN
4� ENTAL UN
ON ACCOUNT OF APPROPRIATION NO. 00 FOR
(OFFICE, BOARD, DEPA EN OA INSTI ON)
DATE FROM TO SPEEDOMETER EADI
AUTO MILEAGE
O� POINT PAINT START FINISH NATURE OF BUSINESS TRAVELED x
PER MILE
O S 2A! 8 #o
58S
Oq Aid HII HA 3
AUTO LICENSE NO. TOTALS 8 C l3
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map. J
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount claimed is le ally du fter allowing all just credits
end that no part of the same has been paid.
Date
Claim No. Warrant No. I have examined the within claim and hereby
IN FAVOR OF certify as follows:
CaA t 'r That if is in proper form.
l That it is duly authenticated as required
by law
That it is based upon statutory authority.
That it is apparently correct
incorrect
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Y3� Disbursing Officer
On Account of Appropriation No. f or o tr a
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