180030 12/08/2009 CITY OF CARMEL, INDIANA VENDOR: 362339 Page 1 of 1
ONE CIVIC SQUARE CITIZENS MANAGEMENT INC
CARMEL, INDIANA 46032 PO BOX 620 CHECK AMOUNT: $13,068.86
HOWELL MI 48844 -0620 CHECK NUMBER: 180030
CHECK DATE: 12/8/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
302 5023990 SWC00000385 13,068.86 OTHER EXPENSES
4 Citizens
Management Inc.,.
�p "I 11 "na'vvv M v—G'o„p Citizens Management Inc., I PO Box 620, Howell, MI 48844 -0620 Loss Fund Invoice
TO: D
MS. SHELLY M. LINGELBAUGH ;f
CITY OF CARMEL DEC 0 7 2009
ONE CIVIC SQUARE
CARMEL, IN 46032
i sy
DATE: 11/30/2009
LOSS FUND INVOICE
REFERENCE AMOUNT DUE
w.
SWC0000385
INITIAL DEPOSIT $25,000.00
11/30/2009 BALANCE $11,931.14
AMOUNT DUE $13,068.86
IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL PLEASE CONTACT US AT: 517 540 -3186
PLEASE NOTE: WE ARE FORBIDDEN BY LAW TO ISSUE CHECKS SHOULD YOUR LOSS FUND BECOME ZERO BALANCE
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
Citizens Management, Inc.
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
11130/09 SWC0000385 Works Compensation Account Re linishment $13
Total $13,068.86
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
r VOUCHER No. 12/07/09 WARRANT NO.
ALLOWED 20
Citizens Management, Inc. IN SUM OF
PO Bo 620
Howell, MI 48844 -0620
$13,068.86
ON ACCOUNT OF APPROPRIATION FOR
302 Workers Compensation
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
302 swc0000385 302 $13,068.86 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Si a re
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund