205218 01/05/2012 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $34.92
CARMEL IN 46032
CHECK NUMBER: 205218
CHECK DATE: 1/5/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 34.92 TRAVEL PER DIEMS
Prescribed by Slate Board of Accounts General f=orm No. 101 (1955)
MILEAGE CLAIM
TO DR.
(Governmental Unit)
2 62- &L On Account of Appropriation No. for
(Ottice, Board, Department or Institutlon�
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE
20 Point Point Start Finish TRAVELED PER MILE
a/ 3
Vi
oz i v� ut 4 t t i 3
i; q t t q S0 _1 5 y
(1 L1 l S5 9 C/ 1�c r'
i
Auto License No. TOTALS
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed Ily due, after
allowing all j credit and that no of the same has been paid. i
Date
Claim No, Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon statutory autho:
3
That it is apparently incorrect
On Account of Appropriation No. y D for
Disbursing Officer
Q 'U
O
Allowed 20
in the sum of
y
(Da'
x
(DQ
(Board or Conunission)
FILED
t
v
C)
i a
0
a
m
(Official Title)
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