162187 07/30/2008 a CITY OF CARMEL, INDIANA VENDOR: 065950 Page 1 of 1
ONE CIVIC SQUARE DIANA CORDRAY
CARMEL, INDIANA 46032 11843 STONEY BAY CIRCLE CHECK AMOUNT: $159.00
CARMEL IN 46033 -9501 CHECK NUMBER: 162187
CHECK DATE: 713012008
1 5EPARTMENT ACCO PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1701 4343004 159.00 TRAVEL PER DIEMS
i
Prepared For Account Number Closing Dale Page 3 of 5
AMERICAN
CRESS DIANA L CORDRAY 07/15108
Neuu Activity continued Amount
07/10108 SOUTHWEST AIRLINES DALLAS TX 159.00
SOUTHWEST AIRLINES��
From: To: Carrier: Class:
INDIANAPOLIS IN F 1 C
DENVER CO WN T r
INDIANAPOLIS IN WN T A
Ticket Number: 52685021157059 Date of Departure: 09 /10
Passenger Name: CORDRAY /DIANA
L. Document Type: PASSENGER TICKET
07/12108' TRA CESSED BY AMERICAN EXPRESS 5.75
BAGGAGE INSURANCE PREMIUM
TKT NO. 52685021157059
Dotal of New Activity 1,240.77
Finance Charges Average Daily Daily Actual ANNUAL Nominal ANNUAL Periodic
Billing days this period: 30 Balance Periodic Rate PERCENTAGE PERCENTAGE FINANCE
RATE RATE CHARGE
Purchases 0.00 0.0411 /ti T 0.00% 14.99% 0.00
Cash Advances 0.00 0.0548% 0.00% 19.99% 0.00
0.00
Certain of the periodic rates and APRs above may be variable. Those rates may vary
based upon the prime rate identified in the Wall Street Journal, as described in your
Cardmember Agreement as currently in effect.
LTA SkyMiies® Account Number:
Current Year to Date 2249570876
Period
Total Miles Earn 1,235 4,936
Remember, you can earn a Miles Boost" of 2,500 bonus miles by reaching $10,000
in eligible spend by December 31st. Your eligible Year -to -Date spend on your Delta
SkyMiles® account is $4,936.00.
Continued on Page 4
Please detach here
Travel Insurance Premium Refund /Credit Form Reasons for Refund /Credit
Please see the back if requesting refunds forTravelAssure, TravelAssure Non -fare airline services charge(s) (e.g. excess baggage,
Classic or I nternational Medical Protection. Otherwise, continue below. itinerary charges, upgrade, or any other non -air transportation charge)
Please fill out this form to request refunds for travel insurance premiums An uninsured person
incurred with the purchase of an airline ticket or a car rental. If you have Non scheduled airline flights (e.g. private jet)
been charged an insurance premium for one of the reasons listedto the Two or more premium charges for same car rental
right, please provide the information requested below. Please deduct Car rental no show
ir the total premium refund amount from your total balance due and Other charges unrelated to actual car rental(e.g., gas)
return this form with your payment. In order to receive a refund, you must Car rental in an excluded country
fill out this form completely. Failure to do so may result in a delay A vehicle otherthan a rental car
a in processing or a denial of your request- Cancelled Trip with non refundable ticket
a Please do not fill out this coupon if you cancelled an airline Other reason
g ticket or a car rental reservation and expect credits for these Account Number:
on your American, Express account. These premiums will be
automatically refunded to you any refunded premiums will 3725 401694 82002
appear as credits on your monthly statement.
Vendor Name TicketlRental Ticket Number Month No. of Premiums Program Total Premium
Amount Billed Refund_Reyuested
"Airline $374-20 001643 Mardi 1 Travel Del $9.95
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
WA Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
�7�0_ 0Amnh
J
Total
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.
r
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
�&p
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
r 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
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund