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HomeMy WebLinkAbout199607 07/20/2011 CITY OF CARMEL, INDIANA VENDOR: 365241 Page 1 of 1 ONE CIVIC SQUARE NEUROPSYCHOLOGY ASSOCIATES I,( r CARMEL, INDIANA 46032 10293 N MERIDIAN ST #210 CHECK AMOUNT: $2,750.00 INDIANAPOLIS IN 46290 -1079 CHECK NUMBER: 199607 CHECK DATE: 7/20/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1110 4340701 2,750.00 MEDICAL EXAM FEES INVOICE July 13, 2011 City of Carmel Police Department 3 Civic Square Carmel, IN 46032 Neuropsychological Assessment for Chad Koebcke $2,750.00 TOTAL AMOUNT DUE: $2,750.00 Please make check payable to: Neuropsychology Associates 10293 N. Meridian 4210 Indianapolis, IN 46290 -1079 Neuropsychology Associates 10293 N Meridian #210 For Professional Services of: Indianapolis, IN 46290 -1079 Christopher Sullivan PhD PhD Indiana License# 20041471 A (317) 581 -2292 FEIN 351995728 Please make checks payable to: Neuropsychology Associates Carmel Police Dept Statement Date: 0710111 1 Attn:Theresa Anderson 3 Civic Square Carmel, IN 46032 Billing period: Ill /I I to 7/1/11 ICD9: 331. Previous Balance: $0.00 Date CPT Description Fee Payment Balance 6/13/11 96119 Koebcke, Chad Neu ropsychological Assessm( $1,250.0( $1,250.00 6/13/11 96118 Koebcke, Chad Neuropsychological assessme $1,500.0( $2,750.00 New Balance $2,750.00 Over 90 Days ......$0.00 61 -90 Days ......$0.00 31 -60 Days ......$0.00 0 -30 Days ......$2,750.00 6000/6000[n XV3 99 :CT TTOZ /TO /LO bf INDIANA RETAIL TAX EXEMPT PAGE C 1 U armel CERTIFICATE NO. 003120155 002 0 PURCHASE ORDER NUMBER LL FEDERAL EXCISE TAX EXEMPT 27M5 35- 60000972 ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES, A/P CARMEL, INDIANA, 46032 -2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS, FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1997 SHIPPING LABELS AND ANY CORRESPONDENCE. PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION 311 M 9 9 Ass acl o C I I ��Ilc�a I �p ate VENDOR SHIP 3 CIVIC Squm 10203 N. Merldlan Stmt, Suite 210 TO Cwmol, IN 4I Indimapallo, IN 4 A 011 CONFIRMATION BLANKET CONTRACT PAYMENTTERMS FREIGHT QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION. Accou 43407.09 I Each applicant eitsr#1 $1.50 $4.500.00 Sub Totad: $1,500.00 I 1 y v lk H o y� t R a 4v y t sr>� �att for .p IIc��4 Ch Itco_ Send Invoice o:' Camd Police Depmrtmen Attu: Tema An darson 3 CIVIC square Camel, IN 2= PLEASE INVOICE IN DUPLICATE DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT Centel Police Dept. PAYMENT $1, A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED. SHIPPING INSTRUCTIONS I HEREBY CERTIFY THA Tpff IS AN UNOBLIGATED BALANCE IN SHIP REPAID. THIS APPROPRIATION' 0 ICIENT TO PAY FORT E.ABOVE ORDER. C.O.D. SHIPMENTS CANNOT BE ACCEPTED. PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY 9 SHIPPING LABELS. Cltl IDP Pol THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945 TITLE b AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. CLERK- TREASURER DOCUMENT CONTROL No- 2 7 735 A .P.V. COPY SIGN AND RETURN TO CLERICS OFFICE VOUCHER NO. WARRANT NO.___._ ALLOWED 2© IN THE SUM OF fI ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT#ITiTLE 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_ T 20 Signature Title Cast distribution ledger classification if claim paid niotor vehicle highway fund Prescribed by 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, number of units, price per unit, etc. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 07/01/11 payment for exam for applicant $2,750.00 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. Neuropsychology Associates ALLOWED 20 IN SUM OF 10293 N. Meridian Street, Suite 210 Indianapolis, IN 46290 -1079 $2,7 ON ACCOUNT OF APPROPRIATION FOR Carmel Police Department PO# Dept. INVOICE NO. I ACCT /TITLE AMOUNT Board Members 27235 43- 407.01 $2,750.00 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 Thursday, July 14, 2011 Chief of Police Title Cost distribution ledger classification if claim paid motor vehicle highway fund