177153 09/15/2009 A. CITY OF CARMEL, INDIANA VENDOR: 363338 Page 1 of 1
ONE CIVIC SQUARE CHELSEA CLEMENTS
e CARMEL, INDIANA 46032 CHECK AMOUNT: $125.00
14013 CHESWICK BLVD
CARMEL IN 46032 CHECK NUMBER: 177153
CHECK DATE: 9/15/2009
DEPARTMENT ACCOU PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTI
1047 4357003 125.00 INTERNAL INSTRUCT FEE
a�
Carmel e Clay
Parks &Recreation
Employee Expense Reimbursement Request
Date of f=und Account Account
Receipt Vendor listed on receipt Line Budget Description Amount Purpose of Expense
n4-r a a 1
S A 09 uro 4 1 4 3 570 05 o -ee_s WS rye.
All receipts should be attached in the same order as listed above.
No sales tax will be reimbursed. TOTAL:
rlP.I'ICVI l .IQI�YI 1 FG2 ua�" xy
Employee Name (prinq f
Address
��lbl3 �Stiyir✓k �Iv� 09 Check payable to: City, St, Zip
Signature: Approved by:
Date: Z5 Date:
Business Services Division, Revised 7 -7 -08
FILE. Shared\Administrative \Forms \Staff Forms \Employee Exp Reimb Request
ACTIVITY SALES RECEIPT
Receipt 257762
Payment Date: 05/12/2009
Household 18185
Home Phone: (317)569 -1620
Work Phone:
MICHAEL CLEMENTS Monon Center
14013 CHESWICK BLVD. Carmel IN 46032
CARMEL IN 46032
Phone: (317)848 -7275
Fed Tax ID #35- 6000972
Enrollment Details
Enrollee Name: Chelsea Clements Fees Tax Discount Prev Paid Cur Paid Amount Due
Activity Number: 193020 -01 Water Safety Instruc 125.00 0.00 0.00 125.00 0.00
Enrollment Date: 05/12/2009 (Enrolled)
Class Location: Indoor Lap Pool Class Dates: 05/06/2009 to 05/13/2009
Monon Center 4:OOP to 9:OOP
M,Tu,W,Th,F,Sa
Carmel, IN 46032 Scheduled Sessions: 7
(317)848 -7275
Fee Details: Fee Description Amoun Count Discount Sal Tax Total Fee
Water Safety Instruc 125.00 1.00 0.00 0.00 125.00
Processed on 05/12/09 16:10:24 by ALC FEES CHARGED ON NEW LINE ITEMS 125.00
DISCOUNT APPLIED AGAINST THESE FEES 0.00
TAX CHARGED ON NEW FEES 0.00
NEW AMOUNT DUE 125.00
PREVIOUS NET HOUSEHOLD BALANCE 0.00
TOTAL DUE 125.00
NEW FEES PAID ON THIS RECEIPT 1 25.00
TOTAL
PAID 125.00
NEW NET HOUSEHOLD BALANCE 0.00
1
Payment of 125.00 Made By VISA/MC Auth: 071116 Card xxxxxxxxxxxx9281 With Reference visa
I agree to pay the above amounts listed as credit card charges according to credit card issuer agreements.
Page 1
ACTIVITY SALES RECEIPT
Receipt 257762
Payment Date: 05/12/2009
Household 18185
Participant: Chelsea Clements
Class List: 193020 -01: Water Safety Instruc (05/06/2009 05/13/2009)
Waiver /Release Statement
The undersigned party agrees to release and to hold Carmel /Clay Parks and Recreation, and its members, agents, and employees harmless from any and all
liabilities and claims for damages and /or suits for or by members, agents, and employees harmless from any and all liabilities and claims for damages and /or
suits for or by reason of any injury or injuries to any person or persons or property of any kind whatsoever from any cause or causes whatsoever while engaged
in any Carmel /Clay Parks and Recreation program and for all claims or demands whatsoever in law or equity which may heirs, executors, administrators, or
assigns can, shall, or may have reason of any matter, cause or thing whatsoever. I also give permission to the aforementioned organization for the free use of
my likeness and that of my child or ward, in connection with any broadcast, telecast, print media or other publicity.
I understand and agree to the activity refund policy that a full refund will only be given when a class is cancelled by Carmel Clay Parks Recreation. A refund
request at least one week prior to the first class meeting will receive everything minus a $7.00 surcharge fee either to the household account, check form or
placed back on credit card. NO REFUNDS will be given after that point. All check refunds are subject to State Board of Accounts claim procedures and may
take up to 3 -4 weeks to process.
I understand and agree to all policies listed in the current Recreation Brochure.
Participant Signature: Date:
(Parent or Guardian Signature if Participant is under 18 years of age)
This Waiver was Processed on 05/12/09 at 4:10P by ALC
Page #2
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.
Terms
Clements, Chelsea
14013 Cheswick Blvd
Carmel, IN 46032
Invoice
4 Invoice Description PO Amount
Date Number (or note attached invoice(s) or bill(s))
125.00
8/23/09 Reimb WSJ Course
Total 125.00
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
-1
Voucher No. Warrant No.
Clements, Chelsea Allowed 20
14013 Cheswick Blvd
Carmel, IN 46032
In Sum of
125.00
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1047 Reimb 4357003 125.00 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
10 -Sep 2009
J
Signature
125.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund