177150 09/15/2009 CITY OF CARMEL, INDIANA VENDOR: 362339 Page 1 of 1
se� yf ONE CIVIC SQUARE CITIZENS MANAGEMENT INC CHECK AMOUNT: $6,611.49
CARMEL, INDIANA 46032 PO BOX 620
HOWELL MI 48844 -0620 CHECK NUMBER: 177150
CHECK DATE: 9/15/2009
DE PARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
302 5023990 SWC0000385 6,611.49 OTHER EXPENSES
�c
r.
r Citizens
Management Inc
"pa of Men„„." In" nmarLrn,p Citizens Management Inc., I PO Box 620, Howell, MI 48844 -0620 Loss Fund Invoice
TO:
MS. SHELLY M. LINGELBAUGH
CITY OF CARMEL
ONE CIVIC SQUARE
CARMEL, IN 46032
DATE:
08/31/2009
LOSS FUND INVOICE
REFERENCE AMOUNT DUE
SWC0000385
INITIAL DEPOSIT $25,000.00
08/31/2009 BALANCE $18,388.51
AMOUNT DUE $6,611.49
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 City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
1 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
Citizen's Management Inc Purchase Order No.
Terms
1
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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 NQ NO.
uu
Citizen's Management Inc ALLOWED 20
IN SUM OF
P.O. Box 620
owell, M! 48844-0620
$6,611.49
ON ACCOUNT OF APPROPRIATION FOR
302 WORKERS COMP
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
WC 0000385 302 $6,611.49 materials or services itemized thereon for
which charge is made were ordered and
received except
20
`gna ur
d Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund