179162 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: 362339 Page 1 of 1
ONE CIVIC SQUARE CITIZENS MANAGEMENT INC CHECK AMOUNT: $13,812.31
CARMEL, INDIANA 46032 PO BOX 620
HOWELL MI 48844 -0620 CHECK NUMBER: 179162
CHECK DATE: 11111/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
302 5023990 SWC0000385 13,812.31 OTHER EXPENSES
y
S
Citizens
Management Inc.,.
Citizens Management Inc., PO Box 620, Howell, MI 48844 -0620 Loss Fund Invoice
D Q a
NOV 0 9 2009
TO: MS. SHELLY M. LINGELBAUGH By
CITY OF CARMEL
ONE CIVIC SQUARE
CARMEL, IN 46032
DATE: 10/30/2009
LOSS FUND INVOICE
.r. e
REFERENCE SWC0000385 AMOUNT DUE
K:
INITIAL DEPOSIT $25,000.00
10/30/2009 BALANCE $11,187.69
AMOUNT DUE $13,812.31
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
M
S 1 �cL"� Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number T (or note attached invoice(s) or bill(s))
U 1Z 31
Total 13
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.u'I Jq, WARRANT NO.
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
30Z 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
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund