204813 12/20/2011 CITY OF CARMEL, INDIANA VENDOR: 365877 Page 1 of 1
f ONE CIVIC SQUARE KAREN GRAY
CARMEL., INDIANA 46032 1311 ORCHARD PARK N DR CHECK AMOUNT: $228.00
INDIANAPOLIS IN 46280
CHECK NUMBER: 204813
CHECK DATE: 12/20/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1092 4358400 228.00 REFUNDS AWARDS INDE
GLOBAL REFUND RECEIPT
Receipt 759198
arm I o Cloy Payment Date: 12/14/11
I arks &[recreation Household 24519
x rit i,z'i a j
Monon Community Center Q ry Op Karen Gray Hm Ph: (317)658 -6801
Carmel IN 46032 1311 Orchard Park N. Dr.
f ?h 5 Indianapolis IN 46280 Cell Ph: (317)658-6801
klgray2 @gmail.com
Phone: (317)848 -7275
Fed Tax ID #35- 6000972 Mr
Pass Details
CANCELLATION Refund Of 228.00
Pass Holder: Caitlin Gray Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: AgGy Yth Mthly (XM AGYM), #107890 133.00 0.00 0.00 133.00 0.00
Valid Dates: 05/28/2010 to 01/14/2012 (Pass Cancellation)
Pass Comments: Children must be age 11 or older to utilize the pools and /or gymnasium unaccompanied by an adult.
Cancel Reason: not using and has 2 passes for the last 12 months. error in pass transfer on original 10/16/10 process
CANCELLATION
Pass Holder: Caitlin Gray Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: MC Yth Mthly (M MCYM), #120228 69.00 0.00 69.00 0.00 0.00
Valid Dates: 09/26/2011 to 10/16/2012 (Pass Cancellation)
Pass Comments: Children must be age 11 or older to utilize the pools and/or gymnasium unaccompanied by an adult.
Children ages 11 -13 may use Fitness Center, but must be under adullt supervision.
Children must be age 14+ to utilize the Fitness Center without adult supervision.
Cancel Reason: not using
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 12114/11 05:24:31 by TLP FEES CHANGED ON CANCELLED ITEMS 361.00
G��� Il SURCHARGE APPLIED AGAINST CANCELLED FEES 133.00
�Y C) NET AMOUNT FROM CANCELLED ITEMS 228.00
S` I TOTAL AMOUNT REFUNDED 228.00
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 228.00 Made By REFUND FINAN With Reference
All refunds are subject to late Board of Accounts claim procedure and may to 4 -6 weeks to process. A check will be
issued. No cash or credit and refund
145h
Authorized Signature Date oriz b atl
Volunteer with Us!
Volunteers are the foundation of Carmel Clay Parks Recreation and we need your help! We are currently seeking volunteers
for special events, adaptive programs, parks and greenways, and Extended School Enrichment. If interested, please call Dana
at 317.843.3868 or register online at https:// 201lcpry .theregistrationsystem.com /en /1033!
Page 1 of 1
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.
Gray, Karen Terms
1311 Orchard Park N Dr. Date Due
Indianapolis, IN 46280
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/14111 759198 Refund 228.00
Total 228.00
1 hereby certify that the attached invoice(s), or bi11(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.
Gray, Karen Allowed 20
1311 Orchard Park N Dr.
Indianapolis, IN 46280
In Sum of
228.00
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1092 759198 4358400 228.00 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
15 -Dec 2011
Signature
228.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund