172267 05/13/2009 CITY OF CARMEL, INDIANA VENDOR: 362339 Page 1 of 1
0 ONE CIVIC SQUARE CITIZENS MANAGEMENT INC CHECK AMOUNT: $2,167.87
4� CARMEL, INDIANA 46032 PO Box 620
HOWELL MI 48844 -0620 CHECK NUMBER: 172267
CHECK DATE: 5113/2009
D EPAR TME NT A CCOUNT PO NUMBER INVO ICE N UMBER AMOUNT DESCRIPTION
301 5023990 SWC0000385 2,167.87 OTHER EXPENSES
Citizens
Management Inc,
Pa" oJnRn,n «c 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: 05/01/2009
LO SS F UND IN
REFERENCE swc 0000385 AMOUNT DUE
INITIAL DEPOSIT $25,000.00 PRIOR AMOUNT DUE $2,100.71
CURRENT CHECKS $2,167.87
05/01/2009 BALANCE $22,832.13
PAYMENTS ($2,100.71)
AMOUNT DUE $2,167.87
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
I
From: 04/01/2009 City of Carmel
Thru: 04/30/2009 Check Register
Check Check
Number Check Date Claim Number DOI Claimant Name Location Payee Amo Type Tr ans
1183233 04/07/2009 0385 -09 -00135 01/14/2009 Graham, Bruce A. Police City of Carmel Robert A Czarkowski MD $52.21 Med Check
1183504 04/09/2009 0385 -09 -00793 02/22/2009 Towle, John R. Police City of Carmel Community Hospitals Of IN $132.93 Med Check
1183505 04/09/2009 0385 -09 -00795 02/20/2009 Oliver, Harold B Parks City of Carmel Community Hospitals Of IN $233.45 Med Check
1184358 04/22/2009 0385 -09 -01012 02/26/2009 Basarich, Lacey Parks City of Carmel Community Hospitals Of IN $87.08 Med Check
1184359 04/22/2009 0385 -09 -00795 02/20/2009 Oliver, Harold B Parks City of Carmel Community Hospitals Of IN $87.08 Med Check
1184360 04/22/2009 0385 -09 -00135 01/14/2009 Graham, Bruce A. Police City of Carmel Robert A Czarkowski MD $81.74 Med Check
1184430 04/23/2009 0385 -09 -01012 02/26/2009 Basarich, Lacey Parks City of Carmel Community Hospitals Of IN $279.12 Med Check
1184431 04/23/2009 0385 -09 -01011 03/05/2009 Spence, Joshua N. Parks City of Carmel Community Hospitals Of IN $87.08 Med Check
1184432 04/23/2009 0385 -09 -00793 02/22/2009 Towle, John R. Police City of Carmel Community Hospitals Of IN $87.08 Med Check
1184598 04/27/2009 0385 -09 -01012 02/26/2009 Basarich, Lacey Parks City of Carmel Third Party Solutions $145.80 Med Check
1184747 04/29/2009 0385 -09 -00135 01/14/2009 Graham, Bruce A. Police City of Carmel One Call Medical Inc $875.00 Med Check
1184844 04/29/2009 0385 -09 -00135 01/14/2009 Graham, Bruce A. Police City of Carmel Indiana Health Network $8.19 Exp Check
1184844 04/29/2009 0385 -09 -00135 01/14/2009 Graham, Bruce A. Police City of Carmel Indiana Health Network $11.11 Exp Check
0385 -09 -00793 02/22/2009 Towle, John R. Police City of Carmel Community Hospitals Of IN $0.00 Med Paper
038 -09 -0 1 0 12 0 2 26/2009 Basarich, Lacey Parks City of Carmel Community Hospitals Of IN $0.00 Med Paper
Number of Checks: 15 $2,167.87
Run Date: 04 /30/2009 09:59:25 Citizens Management Inc. Run By: PMP521
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Farm 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
(;iti7en's Management Inc Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Loss Fund 167.87
Total $2.167.87
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.D& NO.
Citizen's Management Inc ALLOWED 20
P.O. Box 620 IN SUM OF
.veih M, -1U8844-0620
$2,167.
ON ACCOUNT OF APPROPRIATION FOR
302 WORKERS COMP
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify hat the attached invoice(s), or
DEPT. y y
bill(s) is (are) true and correct and that the
30 SWC 000038 302 87 materials or services itemized thereon for
which charge is made were ordered and
received except
20
i
Si atur
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund