167422 12/23/2008 CITY OF CARMEL, INDIANA VENDOR: 354940 Page 1 of 1
ONE CIVIC SQUARE THOMAS PERKINS
CARMEL, INDIANA 46032 14150 EQUINE COURT CHECK AMOUNT: $69.18
WESTFIELD IN 46074 CHECK NUMBER: 167422
CHECK DATE: 12/23/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1180 4343004 69.18 TRAVEL PER DIEMS
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PRESCRIBED BY STATE BOARD OF ACCOUNTS
GENERAL FORM NO. 101 (1986)
MILEAGE CLAIM
c TO
(GOVERNMENTAL UNIT)
ON ACCOUNT OF APPROPRIATION NO. F t
(OFFICE, BOARD, DEPARTME R STITUTION)
SPEEDOMETER MILEAGE
9DA O FROM TO READING NATURE OF BUSINESS M L O 1 Jr'OS'
POINT POINT START FINISH TRAVELED PER MILE
?.57 Rt_ GAlll
god
lO 5' o 5 off 8
AUTO LICENSE NO. TOTALS g
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, I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after Rowing all just credits
and that no part of the same has been paid.
Date 'QAO
Claim No. Warrant No. I have examined the within claim and hereby
IN FAVOR OF certify as follows:
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 correct
U incorrect
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Disbursing Officer
On Account of Appropriation No.
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A.E. BOYCE CO., INC. MUNCH, IN 01136
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