HomeMy WebLinkAbout199663 07/20/2011 CITY OF CARMEL, INDIANA VENDOR: 00350917 Page 1 of 1
ONE CIVIC SQUARE KIM ROTT
CARMEL, INDIANA 46032 CHECK AMOUNT: $17.24
CHECK NUMBER: 199663
ON
CHECK DATE: 7/2012011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4343004 17.24 TRAVEL PER DIEMS
Prescribed by State Board of Accounts General Form No. 101 (1955)
MILEAGE CLAIM
TO �i rh DR.
(Governmental Unit)
C Ouq� On Account of Appropriation No. for r�
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE
2011_ Point Point Start Finish TRAVELED PER MILE
q a
Auto License No. TOTALS 7
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
Date
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as required
by law;
That it is based upon statutory authority;
That it is apparently f correct
l o? `f 1 incorrect
On Account of Appropriation No. ®�o`► for
Disbursing Officer
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