HomeMy WebLinkAbout155791 01/23/2008 CITY OF CARMEL, INDIANA VENDOR: 358817 Page 1 of 1
ONE CIVIC SQUARE JARED KINNEY
CARMEL, INDIANA 46032 10041 SHAHAN COURT CHECK AMOUNT: $2,500.00
INDIANAPOLIS IN 46256 CHECK NUMBER: 155791
CHECK DATE: 1/2312008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 2,500.00 OTHER EXPENSES
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CITY OF CARMEL
ADOPTIom AssISTANCE CLAIM FORM
SEE REVERSE SIDE FOR INFORMATION AND INSTRUCTIONS
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Employee Name (First MI Last): �ac e.A-
Department:
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Social Security Number: `L0 Phone: 3 1 ,57 Z6ct�>
Employee ID Number: Z 6 S Home Phone: 0 O1Zo
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Child's Name: Date of Birth: Z
(if known): '340 Adoption Date:
Attach copy of adoption decree if adoption has been finalized.
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Date: Paid To: Services Rendered: Amount:
Attach original itemized receipts in U.S. dollars for all expenses listed above. No reimbursement will be made without appropriate documentation.
Attach separate sheet of paper for additional expenses.
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I hereby request reimbursement for the adoption expenses listed above_ By signing below, I certify that:
Check appropriate box: The child identified above has been placed in my home pursu t to adoption ;or
The adoption of the child identified above has been finalized ;and
To the best of my knowledge, each expense listed above is a qualified adoption expellse under the City of Carmel
Adoption Assistance Program; and
All statements and documentation relating to this claim are true and complete.
I understand that incomplete or inaccurate information may adversely affect my eligibility for benefits through the
Adoption Assistance Program.
Employee Signature: Date:
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Form HR103 (1/08) Official form cannot be altered or subs4i7uted.
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
Jared Kinney 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.
01/07/08 Adoption Assistar Terms
$2,500.00
Date Due
Invoice Invoice Description Amount
Date' Number (or note attached invoice(s) or bill(s))
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.
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ALLOWED 20
Jared Kinney
IN SUM OF
10041 Shahan Court
,,Indianapolis, 256
$2,500.00
ON ACCOUNT OF APPROPRIATION FOR
GENERALFUND
301 Medical Escrow
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
00 materials or services itemized thereon for
which charge is made were ordered and
received except
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S� nature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund