202937 10/25/2011 CITY OF CARMEL, INDIANA VENDOR: 358408 Page 1 of 1
ONE CIVIC SQUARE TIFFANY BUCKINGHAM
CARMEL, INDIANA 46032 5130 PRIMROSE AVE CHECK AMOUNT: $119.88
se,tr INDIANAPOLIS IN 46205 CHECK NUMBER: 202937
91 «py GD
CHECK DATE: 10/25/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4343000 REIMB 119.88 TRAVEL FEES EXPENSE
PMCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 101 (1986)
V MILEAGE CLAIM
r0 I�
C� 1
l e
ag isc n
tOOVERNMENTAL UNIT)
ON ACCOUNT OF APPROPRIATION NO. FOR
(OFFICE, BOARD, DEPARTMENT OR INST17
SPEEDOMETER AUTO
DATE FROM TO I READING NATURE OF BUSINESS MILES
ZO L POINT POINT START FINISH TRAVELED PER MILE
.�j -�i
T C)LA n UT
n
GT�IV�
d
O
2
1 ri
Z IIl C�1 10 c
I
AUTO LICENSE NO. TOTALS 2
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map. 1
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 aliowing all just credits
and that no part of the same has been paid.
Date
T L 8 2011 JJ
L,
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
358408 Buckingham, Tiffany Terms
5130 Primrose Ave
Indianapolis, IN 46205
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
10/12/11 Reimb. Mileage 8/10 10/12/11 119.88
Total 119.88
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.
358408 Buckingham, Tiffany Allowed 20
5130 Primrose Ave
Indianapolis, IN 46205
In Sum of
119.88
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO# or INVOICE NO. ACCT #/rITLE AMOUNT Board Members
Dept
I
1081 -2 Reimb. 4343000 119.88 1 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
20 -Oct 2011
Signature
119.88 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund