162877 08/20/2008 I
CITY OF CARMEL, INDIANA VENDOR: 359164 Page 1 of 1
f, ONE CIVIC SQUARE KEN MILLER CHECK AMOUNT: $123.20
CARMEL, INDIANA 46032 768 GRACE COURT
Toy `o, CARMEL IN 46032 CHECK NUMBER: 162877
CHECK DATE: 8120/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1150 4343004 123.20 TRAVEL PER DIEMS
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Pr ib.d b7 Stag- Board o; Actmmtu.
Leo moral Form No. tot UCU
MILEAGE CLAIM
(GOVERNMENTAL UNIT)
TO DR.
(OFFICE. BOARD, DEPARTMENT OR INSTITUTION) ON ACCOUNT OF APPROPRIATION N0. FO
DATE FROM I
9 TO SPEEDOMETER
READING+ I AUTO MILE�G.�
2 POINT POINT NATURE OF BUSINESS MILES
pp START FINISH I I TRAVELED PER MILE
I I 4 W
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7
la
11 Li 40
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B I v rc,(C w C'a' 1 KI 0
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II II
AUTO LICENSE NO. I I I
TOTALS
+SPEEDOMETER READING columns are. to be used only when distance between points cannot be determined by fixed mileage or official highway ma.
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 y e. after allowing. all just cred
and that no part of the same has been paid.
Date 3 D
Claim No. Warrant No. I gave examined -the w thin. claim and hereby
IN FAVOR OF Cerny as follows:
That it is in proper form
That. it is -duly authenticated as req fired
by -law.
Tha it is based upon statutory authority.
That it is apparently orr
j incorrect
2 2�
On Account of Appropriation No. for Dis ursing Of icer J
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