HomeMy WebLinkAbout204618 12/13/2011 a F CITY OF CARMEL, INDIANA VENDOR: 365870 Page 1 of 1
ONE CIVIC SQUARE JENNIFER PERRY CHECK AMOUNT: $384.83
CARMEL, INDIANA 46032 2514TH ST NW
«off CARMEL IN 46032 CHECK NUMBER: 204618
CHECK DATE: 12/13/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 384.83 OTHER EXPENSES
Date: 12/12/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: JENNIFER PERRY ICD 9: 78039 2930
251 4TH ST NW
CARMEL, IN 46032
From: 535 COLLEGE DR
To: IU HEALTH NORTH
1 CIGNA 5200
Patient: JENNIFER PERRY 01942270601
251 4TH ST NW Insurance
CARMEL, IN 46032- 2
Patient No: 201100993
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW THANK YOU.
Total Amount Total Paid Balance
$481.04 8865.87 8- 384.83
CPT
ate ti lq£ 5s �.dw'airi t-9` s tr! y i:�. :i� r tJw �`l,. k� r t sr r 7 d 4 k �..j' v.
arges M r Credlts
Ch r
t t� i 'fin rn .��w arr. r.
04/08/2011 ADVANCED LTFF SUPP 1 -ENFR A0427 $475.00
04/08/2011 NTLEAGE A0425 $6.04
06/02/2011 PAYMENT $481.04
12/08/2011 COM_MERICTAL INSUBANCE PAYMENT 5384.83
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 12112/2011
CARMEL FIRE DEPARTMENT
EMERGENCY IVIED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 Federal iD# 356000972
ACCOUNT HISTORY
Bill To: JENNIFER PERRY ICD -9: 78039 2930
251 4TH ST NW
CARMEL, IN 46032
From: 535 COLLEGE DR
To: IU HEALTH NORTH
1 CIGNA 5200
Patient: JENNIFER PERRY U1942270601
251 4TH ST NW Insurance
CARMEL, IN 46032- 2
Patient No: 201100993
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW THANK YOU.
Total Amount Total Paid Balance
$481.04 $481.04 $0.00
CPT
ry""3,u'� iii �!t. ao ',G i E yS 1 �i.'.�"1jl Py„ i ry L�.p ..u. 7} i ,yt. e4 t4 b" [7�' s l 4, �'y` k "t' r N '�,'r. a r
Char�ges k�� Credits
.S,.a.,.v
04/08/2011 ADVANCLD LIFE SUPP 1 EMER A0427 $475.00
04/08/2011 HTL•EAGE A0425 $6.04
06/02/2011 PP_YMENT $481.04
12/08/2011 COMMERCIAL INSURANCE PAYMENT $389.83
12/12/2011 P.EFUND S- 389.83
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
P ry' C4 Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
r
Total 8
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.
ALLOWED 20
Y, IN SUM OF 9S443
-33 x_33
ON ACCOUNT OF APPROPRIATION FOR
bu.ld
w b o D
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
U
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund