173322 06/10/2009 CITY OF CARMEL. INDIANA «swo0n: 355377 Page 1 of 1
ONE CIVIC SQUARE uo|sF|wc
CARMEL. INDIANA 460oz `o�owonpsroWwCnum CHECK AMOUNT: $9�SO
c^nmsL/w 46032 CHECK NUMBER: 173322
CHECK DATE: 6/10/e009
osp��T�smT A000uwT PO NUMBER INVOICE NUMBER x�ouwr oeacmPT|om
I701 4343004 9.90 MILEAGE
Prescribed by State Board of Accounts General Form No. 101 (1955)
MILEAGE CLAIM
r 0 C me l TO DR.
(Governmental Unit)
le r k J rC�crSu r� r 5 -Q On Account of Appropriation No.
O w4 for :Ji(:Zt E-�,o
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE
20 Point Point Start Finish TRAVELED PER MILE
'5/.16 D iviG, ua ff r o ,30'? No r4-A w00ct -JF-*n CusiomP e rv i rwin
Ca r tv e( +b t M N ct 1 .p r
t
Auto License No. TOTALS
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, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
Date
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as required
by law;
That it is based-upon statutory authority;
a( That it is apparently 1 �'tncorrect
On Account of Appropriation I 0._ for
n o Disbursing Officer
O
Allowed 20 O
in the sum of o
x
vFD Q
o yM
(Board or commission) O
(D
FILED m Q-
5"
(D
C)
B m
0
z
m
mM(D
m
M m
M
(Official Title) C
O
0 N