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HomeMy WebLinkAbout200635 08/17/2011 CITY OF CARMEL, INDIANA VENDOR: T357070 Page 1 of 1 j ONE CIVIC SQUARE STATE FARM CHECK AMOUNT: $15.86 CARMEL, INDIANA 46032 PO BOX 2363 BLOOMINGTON IL 61702 CHECK NUMBER: 200635 CHECK DATE: 8/17/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 15.86 AMBULANCE REFUND Date: 08/09/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederailD# 356000972 ACCOUNT HI SIMRY Bill To: NANCY FINCH ICD -9: 7231 7245 78652 E8130 3709 S WEBSTER ST KOKOMO, IN 46902 From: 106TH MERIDIAN To: IU HEALTH NORTH 1 Patient: NANCY FINCH 3709 S WEBSTER ST Insurance KOKOMO, IN 46902 2 Patient No: 201101709 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE, THANK YOU, Total Amount Total Paid Balance $390.86 $406.72 -15.86 CPT Date fi.:- ion De�Ip t Charcies sc Credits 06/20/2011 BASIC LIFE SUPP EMERGENCY A0429 $375.00 06/20/2011 MILEAGE A0425 $15.86 07/28/2011 COMMERCIAL INSURANCE PAYMENT $406.72 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 08/09/2011 CARMEL FIRE DEPARTMENT EMERGENCY MEQ SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 A8 X00? N T I' T fi Bin To: NANCY FINCH ICD -9: 7231 7245 78652 E8130 3709 S WEBSTER ST KOKOMO, IN 46902 From: 106TH MERIDIAN To: IU HEALTH NORTH 7 Patient: NANCY FINCH 3709 S WEBSTER ST Insurance KOKOMO, IN 46902- 2 Patient No: 201101709 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE, THANK YOU. Total Amount Total Paid Balance $390.86 $390.86 $0.00 CPT Date Descrlpti ©n Chaises Credits 06/20/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 06/20/2011 MILEAGE A0425 $15.86 07/28/2011 COMMERCIAL INSURANCE PAYMENT $406.72 08/09/2011 REFUND -15.86 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) 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. j I Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total 1 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. ALLOWED 20 rCt� "`rte IN SUM OF 125 ON ACCOUNT OF APPROPRIATION FOR IL Board Members PO# or DEPT INVOICE NO. ACCT #/TITLE AMOUNT 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 v 20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund