180923 12/30/2009 CITY OF CARMEL, INDIANA VENDOR: 354940 Page 1 of 1
ONE CIVIC SQUARE THOMAS PERKINS CHECK AMOUNT: $13.20
CARMEL, INDIANA 46032 14150 EQUINE COURT
WESTFIELD IN 46074 CHECK NUMBER: 180923
CHECK DATE: 12/30/2009
D'LEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1180 4343004 13.20 MILEAGE
'S
PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 101 (1986)
e MILEAGE CLAIM
(GOVERNMEN AL UNI) FOR
ON ACCOUNT OF APPROPRIATION NO.
(OFFICE, BOARD, DEPARTMEN R INSTITUTION)
SPEEDOMETER AUTO MILEAGE
DATE FROM TO READING
.l8 POINT POINT START FINISH NATURE OF BUSINESS MILES 5- ,IL s
TRAVELED PER MILE
1
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 is legall ue, after allowing all just credits
and that no part of the has been paid.
Date
Claim No. Warrant No. I have examined the within claim and hereby
IN FAVOR OF certify as follows:
That it is in proper form.
That it is duly authenticated as required
by law
That it is based upon statutory authority.
That it is apparently correct
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y3D Disbursing Officer
On Account of Appropriation No Y3oac/ for
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