159536 05/14/2008 GIT- Y -0F CARMEL, INDIANA VENDOR: T361239 Page 1 of 1
6 ONE CIVIC SQUARE R PERRY PARSONS
CARMEL, INDIANA 46032 7504 PERRY CT CHECK AMOUNT: $72.72
MUNCIE IN 47302
o CHECK NUMBER: 159536
CHECK DATE: 5/14/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 72.72 OTHER EXPENSES
f�
L+I 0075239363
Mp BANI(ER5 L,I -FE AND CASUALTY COMP..ANY
-MS
11825 N. PENNSYLVANIA ST, CARMEL, IN 46032: MELLON BANK N.A.
PHILADELPHIA, PA 62 -4
PAYABLE THROUGH MELLON BANK (DE) WILMINGTON, DE 311
PAY. SEVENTY -TWO AND .72/100
DATE CHECK AMOUNT
TO CARMEL FIRE DEPARTME 04/21/2008 *72,.72 i
THE 2 CARMEL CIVIC.SQ
ORDER CARMEL, IN 46032
OF
j
VOID AITER.i80 DAYS AUTHORIZED' SIGNATURE'
(1 °0075239363((' 1 :031b0004 ?1: 2-969 SS8(('
CHECK NUMBER 0075239363 CHECK DATE: 04/21/2008 BLC /BCBBA /BCB
PATIENT NAME PAT.NO. BILLED APPRVD DEDUCT CO -INS PAID
PARSONS ANNA L 200700985 368.o1 363.61 .00 72.72 72.72
203037367- 107509 SERV.DT.- 5 -2 -2007
DATE: 04/19/08 CONTROL NO. 00015405 TOTAL PAID 72.72
CE APR 5 �u
u�
1166
71- 167/
BRANCH 253`
R PERRY OR ANNA `L PARSONS=
TEL 765 289 1400
7504 PERRY CT
MUNCIE, IN'47302
F
5 IQ.-; T.,
N
0 FinancialBan3' M
For
1 ',0 L �,6.6�Ia,520:.2 5 2,L.On
1 ;07490 b6 2
Z
S
Date: 05/01/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
10 r
Bill To: ANNA L PARSONS ICD -9: 78907 7804 78702 78079
7504 N PERRY CT
MUNCIE, IN 47303
From: 420 SPRINGWOOD DR
To: ST. VINCENT INDPLS
1 MEDICARE PART B
Patient: ANNA L PARSONS 316287330B
7504 N PERRY CT Insurance
MUNCIE, IN 47303- 2 BANKERS LIFE
Patient No: 200700985 203037367
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$368.00 $440.72 -72.72
CPT
Date Description Charges Credits
05/02/2007 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
05/02/2007 MILEAGE A0425 $18.00
06/08/2007 MEDICARE PAYMENT $290.89
06/08/2007 ASSIGNMENT MEDICARE $4.39
08/31/2007 CORRECTION $0.00
10/26/2007 PAYMENT $72.72
04/25/2008 COMMERCIAL INSURANCE PAYMENT $72.72
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 05X01/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MEDSVCS
2 CIVIC SQUARE
CARMEL. IN 46032
(317)571-2805 Fed*ra/lD# 356000972
Bill To: ANNA PARSONS ICD-9: 78907 7804 78702 78079
75O4N PERRY CT
MUNCIE, IN 47303' From: 420 SPRINGWOOD DR
To: ST. VINCENT-INDPLS
1 MEDICARE PART B
Patient: ANNA PARSONS
75O4N PERRY CT Insurance
MUNCIE, IN 47303' 2 BANKERS LIFE
Patient No: 200700985
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
|8 DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
CPT
Date Description Charges Credits
05/02/2007 ADVANCED LIFE 3DPP l-EMER A0427 $350.00
05/02/2007 MILEAGE A0425 $18.00
06/08/2007 MEDICARE PAYMENT $290.89
06/08/2007 ASSIGNMENT MEDICARE $4.39
08/3I/2007 CORRECTION $0.00
10/26/2007 PAYMENT $72.72
04/25/2008 COMMERCIAL INSURANCE PAYMENT $72.72
05/01/2008 REFUND $-72.72
APPROVED BY THE STATE BOARD 0F ACCOUNTS FOR CITY OF CAnMEL.1eee
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))
7
Total 7
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
IN SUM OF 7 02- 7, 2
750 �e
-�2 7,1
ON ACCOUNT OF APPROPRIATION FOR
af1,GL �C/'I /1lo f l�
Board Members
PO# or INVOICE NO. ACCT #/TITLE 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
(7 2
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund