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177806 09/29/2009 CITY OF CARMEL, INDIANA VENDOR: 241763 Page 1 of 1 0 ONE CIVIC SQUARE PETTY CASH CARMEL, INDIANA 46032 C10 LISA CHECK AMOUNT: $265.13 c/0 L SA CHECK NUMBER: 177806 CHECK DATE: 9/29/2009 DEPA RTMENT ACC OUNT PO NUMBER I NUMBE AMOUNT DE SCRIPTION 601 5023990 90.29 OTHER EXPENSES 651 5023990 174.84 OTHER EXPENSES_ 4 �i DESCRIPTION OF ITENUSERVl PURCHASED, AMbUNT CHARGE T O ACCOUNT TOTAL PETTY CASH NUMBER DATE--, V DESCRIPTION OF V e CHARGE TO ACCOUNT TOTAL (P' Receive y Approved By 9672 PETTY CASH NUMBER DATE DESCRIPTI OF e t sU CHARGE TO ACCOUNT TOTAL mmo Received By p. oved By 9672 PETTY CASH NUMBER DATE DESCRIPTION OF ITEWSERVICE PURCHASEO, CHARGE TO ACCOUNT TOTAL Received B r ed B Y App Y 9672 PETTY CASH NUMBER DATE a'l 636�.ns y o DESCRIPTI Or ITEWSERVICE PURCHASED o 4 CHARGE TO ACCOUNT TOTAL Received By Approved By 9672 C EL:. �Ijl "tiL, G,-r. ol _ilitd -c:'�� 0 t tom`_ N! M S `-1-!="_ VLT s':' NA MM I� OT n VLIIES N] ME 138 SavED600-* -ILI AN 01 N1 ME AS bbBKO600C 'DO' i T o �'�'1'= wi ME so 0820600-Z rtC; -al _'c,' oifiC.l 'u Ct1 't i!;';!. Gravel Conveyors, Inc. anipping 5005 W. 106th St. Zionsville, IN 46077 Phone (317) 873 -8686 Fax (317) 873 -9431 DATE: June 16, 2009 Bill To: Carmel Water Department Ship To: pick up Comments or Special Instructions: SALESPERSON P O. NUMBER;? SHIP DATE .SHIP VIA F.O B POINT TERMS Sara UPS Ground cod QUANTITY DESCRIPTION.. UNIT PRICE ::....AMOUNT 1 61VIPS6 hydraulic fitting 9.94 tax exempt 00031201550010 SUBTOTAL 9.94 TAX RATE 0.00% SALES TAX SHIPPING HANDLING 10.00 TOTAL 19.94 THANK YOU FOR YOUR BUSINESS! Transaction Receipt Page 1 of 1 GRAVEL CONVEYORS INC 5005 W 106TH ST ZIONSVILLE, IN 46077 -0000 3178738686 Store #1001101185 06/16/09 01:46:58 PM MO /TO Sale Billing Address Credit Card Information Greg Hollander CREDIT CARD NUMBER: sa. F3i 1054 Bristol Road SWIPE CARD: No Indianapolis, IN 46280 STATUS: APPROVED 053166 ORDER NUMBER: 10. 174.5.141- 121EA64AF31- 62BF7B80- 320284C8 PO NUMBER: 01 Qty Unit Cost Extended Cost 1 19.94 19.94 SUBTOTAL: $19.94 I TOTAL: $19.94 j I AGREE TO P AB F MOU T ACCORDING TO CARD ISSUER. f lAA SIGNATURE X S Gr ollander https: secure .Iii-kpt.net /lpc /ser /LPCPage 6/16/2009 VOUCHER 093096 WARRANT ALLOWED 241763. IN SUM OF PETTY ",CASH ADM IN C/O LISA Carmel Water Utility Ij ON ACCOUNT OF APPROPRIATION FOR Board members PO INV ACCT AMOUNT Audit Trail Code 092809 01- 6200 -06 $19.94 092809 01- 6200 -08 $11.35 092809 01- 6360 -03 $5.00 092809 01- 6360 -08 $54.00 Voucher Total $90.29 Cost distribution ledger classification if claim paid under vehicle highway fund Prescribed by State Board of Accounts City Form No. 201 (Rev 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show, kind of service, where performed, dates of service rendered, by whom, rates per day, number of units, price per unit, etc. Payee 241763 f PETTY CASH ADMIN Purchase Order No. C/O LISA Terms Due Date 9/23/2009 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 9/23/2009 092809 $90.29 hereby certify that the attached invoice(s), or bill(s) is (are) true and ;orrect and I have audited same in accordance with IC 5- 11- 10 -1.6 9/ s/7 Date. Officer Bureau of Motor Vehicles Transaction Receipt IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII BM, 1 State Form 51717 (4 -04) Branch: CARMEL STARS (527) Date: 7/21/09 Time: 4:13:56 pm EDT Visit ID: 150637536 Your Visit Time Today: Visit Customer: DAVID L TURNER Transaction Time 00:30:33 Written Test Time 00:50:13 Total time 01:20:46 Hrs.Min.Sec Transactions Trans ID Trans Tyoe Trans Subtype Amount 168142800 Driver Issue CDL Learner New $16.00 168143362 Driver Amend License Amend $0.00 Subtotal: $16.00 Sales /Use Tax: $0.00 Total: $16.00 Payment Method Am oun t DL Number Authorization Number Name CASH $16.00 Total Due: $16.00 Amount Paid: $16.00 Change Due: $0.00 Charges to your credit card will appear as a line item charge not as a total transaction charge. Page 1 of 1 111111 II�II VIII ��II �II �I VIII I��I� IIII� I�I�� II�I III�� VIII VIII II� 5 1 7 1 7 1 6 8 1 4 3 3 6 2 Ej r Right Store. Right Price, 1217 S. RANGELINE RD. 317 -816 -4818 YOUR CASHIER WAS SELF CHECKOUT KROGER PLUS CUSTOMER t x207el KRO VP CFFEE 4.88 F Fria 0.00 -:Y BALANCE 4.88 CASH 5.00 CHnNGE 0.12 TOTAL HUMBER OF ITEMS SOLD 1 01/29!09 01:27pm 959 82 51.999 3 Ways to Save More Often on Fuel Save $0.10 per gal for every 2 Rx sc.rIPis you fiil. 1 script 50 pornis Save $0.10 per gal for every $50 in gift cards. $1 in Gift Cards: 2 Points Excludes Kroger Gift Cards Save $0.10 per gal for every $100 irl groceries. $1 1 Foist Today's Fuel Saver Points earned -4 April Fuel Saver Points to date-46 100 Points =l fill up. save $0.10 ga. Save an dddi1ionaI $0.05 Per gal with your 123 Rewards MasterCard. Resiriclions and Fxciusrons Apply. See Store for Complete Details. April Points expire- 5/31/09- kk1! lkif%# ttififlENlfMi4iElflf#! Flfi{'M3fiENif1lifdflF •SEE WHAT YOU ARE SAVING TODAY= BY USING YOUR KROGER PLUS CARD,YOUR ANNUAL SAVINGS TO DATE IS $93.00 THANK YOU FOR SHOPPING KROGER CUSTOMER SERVICE IS EVERYONE'S JOB. LET ME KNOW HOW WE ARE DOING. CHARL BECHEL, MANAGER ra r Right Stor Right P rice. 1217 S. RANGEL.INE RD. 317° -846 -4818 YOUR CASHIER WAS SELF CHE=CKOUT KROGER PLUS CUSTOMER tt *2074 MXWL HS COFF *.**PC 9.06 F SC 2280 MXWL. HS COF (5.99) 3.07 -F SC 003 MAXWELL HOUSE 1,00 -F TAX 0.00 t. *k* BALANCE 4.99 CASH 5.99 CHANGE 1.00 TOTAL', IJUMBER OF I LEMS SOLD 1' KROGER SAVINGS t *tt KROGER PLUS SAVINGS 4.07 TOTAL Sf%VINGS (44 pct.) 4.07 KROGER SAVINGS 01126;09 11:42am 959 81 28 999 *i4 Kroner Plus Fuel Rewards Prior months remaintn9:$107 Redaem b:a 1/31/09 3 Ways vi Save More Often on Fuel Save $0.1:3 per gal for every 2 Rx scripts you fill. 1 script 50 points Save $0.10 per gal for ever�.r $50 in gift cards. $1 in Gift Cards= 2,po ints Save $G 10 per gal for every $100 in groceries. $1 1 point Today's Fuel Saver Points earned -4 Jan. Fuel Saver Points to date =48 100 point3 =1 fill up, save $0.10 gal Save an additional $0.05 per gal with your 123 Rewards MasterCard. Restrictions and Exclusions Apply, See Store for Complete Details, Jan ary points expire 2;28109 *SEE. WHAT YOU ARE SAVING 100AY* YOU SAVED $4.07 WITH YOUR PLUS CARD BY USING YOUR KROGER PLUS r_ARD,YOUR ANNUAL 5'r1VINGS TO DATE IS $15.79 THANK YOU FOR SHOPPING KROGER CUSTOMER SERVICE IS EVERYONE'S JOB. LET ME KNOW HOW WE ARE DOING. CHARL BECHEL, MANAGER �f V r® er alobt Store. Right PrICO. 1 1 RANGELINE R[J. YOUR WAS S[LF CHECKOUT K1 PLUS CUSTOMER x) Q074 0 VP CFFEE 4.88 F .19 T SC 19 .19-T 7 95 CASH 5.00 0SH 1.00 CEMGF. 0.05 T01 A1. 'JI Mil OF tll-MS rl; F, 4 it 0.19 10THL, 3AVANG3 pci 0.19 KROGER SAVINGS i)3/04/09 01 :1".-,3pm 959 82 60 999 3 Wags to Save More Men on Fuel Save: per g for every 2 Rx cripis .jou j script 50 Points $0.'10 Pet' qal for every $50 in Miff -CIS. $1 i G,f i C ards= Points Excludes Kroger Gii�i Save $0 '10 Per gal for eversj $lCio in 9t $1 1 Point Today's Fuel Saver Points earned=5 Mar. Fuel Saver Points to date-5 100 polnis=l i'll] up, save $0.10 )al, Save an additional $0,05-p gal With �ickw 123 Rewards Maste, Restrictions and Exclosions Appki. seek.Slore for complete Details. March points expire 1/01/09 �51EE WHAM YOU ARE SAVING FODAY�i OU SAVED $0.19 WITH YOUR PLUS CARD BY 161(dG YOUR KROGER PLUS CAMYOUR ANNUM_ 1 AVTNGS TO DATE IS $51 .92 THANK, YOU FOR SHOPPING KROGER CUS'iOMER SERVICE IS EVERYONE'S JOB. LET HE KNOW HOW WE ARE DOING. Clj,PRL BECHEL, MANAGER' L Pt ^cF_ TEAR HERE Bureau of Motor Vehicles III` IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII i t Illllllllllllllll II IIII II II k Transaction Rece p g U State Form 51717 (4 -04) Branch: INDPLS AMERIPLEX STARS (508) Date: 9/9/09 Time: 9:42:25 am EDT Visit ID: 151834416 Your Visit Time Today: Visit Customer: HAROLD B OLIVER Wait Time 00:00:21 Transaction Time 00:04:36 Total time 00:04:57 Hrs.Min.Sec Transactions p Trans ID Trans Tyve Trans Subtype Amount 170028394 Driver Renew CDL License Renew $30.00 170028665 Customer Voter Registration New $0.00 Subtotal: $30.00 Sales /Use Tax: $0.00 Total: $30.00 Payment Method Amount DL Number Authorization Number Name CHECK $30.00 *3135 HAROLD B. OLIVER Total Due: $30.00 Amount Paid: $30.00 Change Due: $0.00 Charges to your credit card will appear as a line item charge not as a total transaction charge. Page 1 of 1 II VIII VIII VIII VIII III II VIII VIII VIII VIII VIII VIII VIII VIII III 5 1 7 1 7 1 7 0 0 2 8 6 6 5 H�_ a American Health Network Of IN LLC Hamilton County 18051 River Ave Ste 200 e -t m Noblesville, IN 46062 (317) 773-0002 PATIENT NAME i SSN DOB I AGE I SEX MEDICAL RECORD 'CREATE DATE 1 SEO N Epp, Gregory A #/f# -ft 581 06/11/197 39 yrs. M 67396 08/27/09 16 PATIENT ADDRESS i PHONE :APPOINTMENT 'DETAILS 3288 Cicero Road Lot 49 1 (H) (317) 656 -0891 Date: 08/27109 CDL Noblesville, IN 4606 I tw► 31 7) 571 2645 rxn,B:10:0 A INSURANCE INFORMATION i GROUP NAME GROUP NUMBER BER POLICY NUMBER EVENT Sagamore Network Inc Sag 1056 11 33.. 0248173 Annua Physical 45 RENDERING PHYStCU N ttitkME REFERRING PrtYSiCiAN NAME REFERRING i. albn LAST PRIMARY OX !Next Futu:e Appointment i ENCOUNTER Habig MI D, Robert i Iarli MD, Rabe!? 4 660 1173344 9 AMOUNT OF _ASE PAYMENT DATE OF LAST PAWAENT CHART BA'- PATENT ",t5 EALANCE i PATIENT SELF BALANCE ifnaom9 E-xternal x i niernai?; tvliSC iNFO $20.00 08/17/2009 $54.00 54.00 $0.00 p -t •r .cus rs_s: acs: sw: u; —,z ?scuats ur t '1 'a Yc d' L 3`u 'rkt� r _�!x Yi �i 77 -a._ ._r -a- sy.m- yvm:wmnmm...mr iZ PETTY CASH NUMBER DAT DESCRIPTION OF ITEM/SERVICE PURCHASE CHARGE TO ACCOUNT TOTAL 9672 By Approved By s�2 j DESCRIPTION OF ITEM /SERVICE PURCHASED AMOUNT CHARGE T A CC O UNT PETTY CASH NUMBER DATE o/; D g 5 q CHARGE TO ACCOUNT TOTAL Received By /`y Approved By 9672 a PETTY CASH NUMBE DATE e s r CHARGE TO ACCOUNT TOTAL Received B Y 4 pj roved B 9672' AN K�,,1 acne 96 ,50 A i F ?s{ "lers, 2 Hos, i Shared IT Oil 02; 200t'` 10:12 'L 0002' Oweet 33.50 33 50 lay, [h:f m!)L 0,III,) 2 Order a 1 33, 50 I "la l i�U F ri' bhoosing KOfachle Factory a t;isiory ,:t goad taste, rar;r;hi;:ses Available PETTY CASH N UMB DATE 9 51L; .x "CHARGE TO ACCOUNT TOTAL Received By Approved By 9672 PETTY CASH NUMBE DATE S lI t Lo �3 s y :'CHARGE,MAPOOUVT TOTAL Received By Approved By 9672 PETTY CASH NUMBER DATE DESCRIPTI 0 J OF e o� Pc 0 CHARGE TO ACCOUNT TOTAL Received By Approved By 9672 VOUCHER 096475 WARRANT ALLOWED 241763 IN SUM OF PETTY CASH ADMIN C/O LISA Carmel Wastewater Utility ON ACCOUNT OF APPROPRIATION FOR Board members I INV ACCT AMOUNT Audit Trail Code 092809 01- 7040 -01 $40.00 092809 01- 7042 -06 $46.00 092809 01- 7202 -05 $33.50 092809 01- 7200 -08 $16.34 092809 01- 7360 -07 $12.00 092809 01- 7360 -08 $12.00 092809 01- 7500 -02 $15.00 Voucher Total $174.84 Cost distribution ledger classification if claim paid under vehicle highway fund ,Prescribed by State Board of Accounts City Form No. 201 (Rev 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show, kind of service, where performed, dates of service rendered, by whom, rates per day, number of units, price per unit, etc. Payee 241763 PETTY CASH ADMIN Purchase Order No. C/O LISA Terms Due Date 9/23/2009 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 9/23/2009 092809 $174.84 cc hereby certify that the attached invoice(s), or bill(s) is (are) true and :orrect and I have audited same in accordance with IC 5- 11- 10 -1.6 `3 Date Officer DESGRiPTION OF ITEM /SER1/ICE PURCHASED.. AMOUNT' CH T ACC PETTY CASH hl,JMBER 00041,66 1 DESCRIPTION OF ITEM/SERVICE PIJRCH,�SED CHARGE TO ACCOUNT TOTAL Received By Approved By 9672 f I t PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FO RECEIPT 9 8 8�1 HAMILTON COUNTY AUDITOR C� C� •S�. FUND NOBLESVILLE, IN, y��` 20 RECEIVED FROM THE SUM OF C) �uL� DOLLARS loo ON ACCOUNT OF G �,S PAID BY: H El CHECK M.O. AUTHORIZED SIGNATURE CIB LOT 3 350 W SOUTH ST DENISON PARKING 317 636 -8552 WED 02 -18 -09 07:41 A FEE: 5.00 Cash 5.00 Change 0.00 PETTY CASH NUMBER DATE U. 02.d, q �D CHARGE TO ACCOUNT TOTAL �D Received Approved By 9672 DESCRIPTION OF ITEWSERVICE PURCHASED'= AMOUNT CHARGE f I r g 4 V K/' 4 3'x A Hamilton County Recorder ?enn? ter l Hayden 07/10/2009 08: Trans 0: 000 201701 z Business Date: 07/101 Re•. By: CAF 2009041939 FEL SEW LPG 0¢:23:01A, Subtotal; $12.00 r Receipt Total: t C) Paid By Amoun Ch eck• I .n rz+ .n r5 r� s CITY OF CARMEL n n iv r•.� .o r Fcvd From; CITY OF CARMEL T r4 Fri MONEYGRAM P 11 X r" P1easc REao efvfxse siof A OE 13OXY9476MS• INC. DRAWER HAVE "A NICE DAY G7 r'•J MINNEAPOLIS, x• WWW .m°ne MN 55 m80 ram.co r"i a s 576g54bb.53 Y rvY DATE /AMOUNT y 095 N1� OSf 19%2005 W o r� 702')'06 5.0p „oo� 7 5 76854 6 6531 WDETAC H HE 860 EMPLOYEE (10/06) 700/14000 RE M 93037 -P .?tea Am. erican. IF PAYING BY CREDIT CARD, FILL OUT BELOW CHECK CARD USING FOR PAYMENT Hl",walth. �I D❑ISCOVER ;-s MASTERCARD VISA N CARD NUMBER AMOUNT SIGNATURE EXP. DATE lei �iolo STATEMENT DATE PAY THIS AMOUNT ACCOUNT NBR 08/28/09 $0.00 41193 TAX ID NUMBER SHOW AMOUNT 352108729 PAID HERE ADDRESSEE: REMIT TO: J��LIL�IL��II��II�� Inl�il��llnnlln��l�l Bell, Darryl W Hamilton County 711 Lakeview Dr American Health Network Of IN LLC 18051 River Ave Ste 200 Noblesville, IN 46060 Noblesville, IN 46062 USA Please check box if above address is incorrect or insurance information has changed, and PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT indicate change(s) on reverse side. American Health Network Thanks You DATE PATIENT NAME PROVIDER CPT4 DIAG DESCRIPTION OF SERVICE AMOUNT 08/12/09 Bell Darryl Kirsch MD William 99396 V700 Preven Meds Estab Pt 40 Thru 64 (QTY 1) $154.00 08/12/09'` Patten Pay C heck (QTY:1} $20: ,._..v a a q I te r Fr"�.z „ai•% €rti a e �v r o,,,,,,o „a 54�� 6 I��f �.,�,�,,,,.u� er.�,,. ..zC „a,,,. ..,,ewNEc.,,, an.. .,:'.yz., �Fxa>aKn, lu,,,. „h�,iio cii .f,', i.. ;.�,»al ..NJ /ei.n:r. x!' r a.L',.5.� k:• N. C L. ..a.u ..�.m� ✓,.w .....,;>&w:y.._,' _,,..i.i' m .._..,:.4:a�:f,:._: a k re .y 3° .�.�is,.._` _»'a�� :r� .l, v��d&e•�' ._...'�r.� ._..s�.w'�a..�,.. o, �AaGwU sttueI a B i, xnr i, rF T' r b S i,✓. 3 j,. xaaa cr• 't. a '3 'zk_ak' ..a'.. s�c_,,, s_; "asa..,..a e .•..ez, `..w..m.w. a. a 5 i -l p ct ...u.a..._ _.,o�a...._122 •:::sue _,,.:-E'm .us..... _:.�,:i_,.....»;t..,.a�. �u �ts _..s�_.°....�__,��' y ACCOUNT NBR CHARGES PAYMENTS REFUNDS/ ESTIMATED BALANCE DUE BALANCE DUE FROM PATIENT DJUSTMENTS FROMINSURANCE 41193 $154.00 $20.00 $0.00 $134.00 $0.00 MESSAGE: PLEASE PAY All charges and payments are subject to review. $0.00 THIS AMOUNT PAYMENT DUE UPON RECEIPT'` THANK YOU ENCOUNTER INVOICE PAGE: 1 fo r�o er N r Right Store. Right Prue. 1217 S. RANGELINE RD. f 317 846-4818 YOUR CASHIER WAS Ellen KROGER PLUS CUSTOMER KRO VINEGAR 1.59 F 1� KRO VINEGAR 1.59 F TAX 0.00 BALANCE 3.18 p *4228 REF 759761 CREDIT CARD 3.18 CHANGE 0,00 g TOTAL NUMBER OF ITEMS SOLD 2 08/21/09 05:20pm 959 10 250 130 SN *Kroger Plus Fuel Rewards* Prior months S$ remaining;$214 r Redeem by 8/31/09 a e 3 Ways to Save More Often on Fuel Save $0,10 Per sal for every 2 Rx scripts you fill. 1 scripi 50 points t Save $0.10 Per gal for every $50 in gift cards. $1 in Gift Cards= 2 points Excludes Kroger Gift Cards Save $0.10 Per gal for every $100 in groceries. $1 1 point Today's Fuel Saver points earned -3 1 Aug. Fuel Saver points to date =143 100 Points =l $0.10 discount per gal Save an additional $0.05 per gal with your 123 Rewards MasterCard. r Restrictions and Exclusions Apply. See Store for Complete Details. August points expire 9/30/09 *SEE WHAT YOU ARE SAVING TODAY i BY USING YOUR KROGER PLUS CARD. ANNUAL SAVINGS TO DATE IS $16`" THANK YOU FOR qw"n f r� ®r Sight Store. Right Price. 1217 S. RANGELINE RD. 317 846 -4818 YOUR CASHIER WAS SELF CHECKOUT KROGER PLUS CUSTOMER *2079 KRO COFFEE 4.88 F KRO COFFEE 4'.88 F TAX 0.00 BALANCE 9.76 *6515 REFU: 253084 CREDIT CARD 9,76 CHANGE 0.00 TOTAL NUMBER OF ITEMS SOLO 2 06/18/09 01:21pm 959 85 62 999 *Kroger Plus Fuel Rewards Prior months SS remaining:$166 Redeem by 6/30/09 icVN C0A1. 1lAit Me0A'nn All 0 iflflf�f *lflflf *IFlfak 3 Ways to Save More Often on Fuel Save $0.10 per sal far every 2 Rx scripts you fill. 1 script 50 points Save $0.10 per sal for every $50 in gift cards. $1 in Gift Cards= 2 points Excludes Kroger Gift Cards Save $0.10 per sal for every $100 in groceries. $1 1 point Todaa's Fuel Saver Points earned =9 June Fuel Saver Points to date -93 100 points =l fill up, save $0.10 sal Save an additional $0.05 per sal with Your 123 Rewards MasterCard. Restrictions and Exclusions Apply, See Store for Complete Details, June Points expire 7/31/09 *SEE WHAT YOU ARE SAVING TODAY* BY USING YOUR KROGER PLUS CARD,YOUR ANNUAL SAVINGS TO DATE IS $206.75 THANK YOU FOR SHOPPING KROGER CUSTOMER SERVICE IS EVERYONE'S JOB. LET ME KNOW HOW WE ARE DOING. CHARL BECHEL, MANAGER PLEASE TEAR HERE RECEIVE $25 OFF YOUR FIRST PURCHASE WHEN YOU OPEN A 1 -2 -3 REWARDS MASTERCARD COMPLETE .ITEMS IN BOLD TAKE TO CUSTOMER SERVICE 't0 APPLY FOR THE 1 -2 -3 REWARDS MASTERCARD DATE 06/18/09 STORE 4 959 REGISTER 4 85 CASHIER U 999 DIVISION CODE: 021 CREDIT CARD APPLICATION FULL NAME PLEASE PRINT STREET ADDRESS- PLEASE PRINT CITY /STATE /ZIP PLEASE PRINT PRIMARY PHONE NUMBER DATE OF BIRTH SOCIAL SECURITY 4 BANKS ARE REQUIRED TO OBTAIIJ 3 VERIFY YOUR SS# AS PART OF Itch 11 AI'RIOI ACT MOTtIER'S MAIDEN NAME------------- CHECK ANNUAL HOUSEHOLD INCOME* $12,000 $29,999 $30,000 $39,999 $40,000 $69,999 $70,000 $89,999 $90,000 $119,999 $120,000 RSVP B4: KVCR421107020740905 *You do not need to disr_los- alimony, child support separate mainiena_n' if you do not it consider' repayln to •ate L i'?.- s Res F. 1132N'824 o Co 'M' 0, MEN a 0FEIREN s OR WITH FUOdCHASE 0 WITH THE PURCHASE OF MY :r OF 2 ENTREES 0 EUREEAT REGULAR PRICE Q roMwa�d.n �l'a>a dGr. gt0959�0 xaroh.:maro:a Nth ®1aAe:. gt0959W i ®au ma:Ei On ro ur5:de� ®M VOUrRi AUM UMSU r� tl MCIEs CYNHEN YOU COMBINE BOTH YOUR HOME AND AUTO WITH mean ®/��aes ®a�ss�ac ®iav�ag�eas PLEASE CALLY aeARLA ESPANOL f °ETJ�iGI�a�Jot 79 I 1_IU a 444 w e A or. 7 V D o o WorCrs Includes Expires 81311109 is t p,...� NO EXTRA CHARGE FOR SUVS; Y °"V' W 4x S. VANS, OR PICKUPS. GI eID> CO9t NOT VAUD WITH OTHER COUPONS. 1 Wheel Bright Underhody Wash 8 e UB Rust Inhl6 w s9� `ro�i b�iva 7 7 71 1 1 Oil Y i t m I (ro N .:....o�. g any wheel alignment I Inspect f hiGe w m� Aachlretions I l ioad test vehicle The experience you want`s MIS Range Line Road I X317. 848 -5886 eensae ntaDooteN�d '�trsstoncl ramunuttana 1 A KRO959AW 46032 ti �esea it Im Rao Y0 gEg�� W 4)a,III 8 u° m9 Q9Nlfa6ll 13 o it z;p° E o� e lTJ' 5C 4i g R n a Y9i a l�V 14— 0` W a moo• th 8 �s k 'm se .r I'I[�J1�JrI''eI1t,JI1'.�'d7I I�';.:`. S �rg og W IR W ;2223 F. 116th 32 a C iek IM 48622, MEN WP 0 N EN IA M o WITH HURCHASE 'B WITH THE PURCHASEFAHP OF 2 ENTREES 9 ENTREE AT REGULAR PRICE Nmit b. .".tlhmrath.ofk,,, KRO959W Oe earoGwnb�md vNh anlakr aflm. KR0959�M1 ®a VOUR AUM UMSUMaCIE A On Your Side- WHEN YOU COMBINE BOTH YOUR HOME AND AUTO WITH 9W aGil4U ®R7�n^70 ®[E 0C•7S56DLR3'%lT7. CIE re AUT01a ;rEgs PLEASE CALLrlT�- .�MAy.,S,LA ESPANOL �CAJ!IACJJ�O t:l vwwa4tu '�pQ�dO I. .a w 30 O D ay sy only "15 R.og Now Open in front of Meijer, on West Carmel Drive Let yourself shine. suntaneltyeom Valid at all Indianapolis area salons. umlt one per customer. valid on Fast level equipment. See salon for more details. Ezplres 11115/09. KR0919AM, 46032, ATTENTION CASHIERS: Start this tape 04- 20 -09' RTUI, L11 A hango &r filter 4 4 7 I finerµ, to 5 quarts of cam, ([D I f Right Store. Right Price. r 1217 S. RANGELINE RD. 317 846 -4818 YOUR CASHIER WAS Ellen t KROGER PLUS CUSTOMER KRO VINEGAR 1.59 F `4 KRO VINEGAR 1.59 F TAX 0.00 *xr BALANCE 3.18 +tr'��txk�xi�kti:�9228 REF4: 759751 4 CREDIT CARD 3.18` CHANGE 0.00 TOTAL NUMBER OF ITEMS SOLD 2 R. 08/21/09 05:20pm 959 10 250 130� *x *Kroner Plus Fuel RewardsR G �a Prior months remainins:$214 �t Redeem by 8/ 3 Ways to Save More Often on Fuel Save $0.10 Per gal for every 2 Rx scr•iPts you fill. 1 script 50 Points n it Save $0.10 Per gal for every $50 in gift cards. $1 in Gift Cards= 2 Points Excludes Kroger Gift Cards Save $0.10 per gal for every $100 in groceries. $1 1 Point' ri Today's Fuel Saver points earned -3 Aus. Fuel Saver Points to date =143 of 100 points =l $0.10 discount Per gal Save an additional $0.05 per sal with your 123 Rewards'MasterCard. Restrictions and,Exclusions Apply. See Store for Complete Details. August Points expire 9 /30/09 *SEE WHAT YOU ARE SAVING TODAY* BY USING YOUR KROGER PLUS CARD,YOUP, a ANNUAL SAVINGS TDJ RTE IS $165.89.' THANK YOU FOR SHOPPING KROGE CUSTOMER SERVICE IS EVERYONE LET ME KNOW HOW WE ARE DOI L MANAGER C ��J P S�c �P� OpxOQxy�Gp`�, xy N 1 O� 1 i SC,P� All r` N �IVIII�I:l17ra'�t?k`; 1f�1 I�W� ®19��1�t�i Letyoursel shine. Suntancityeom W Valid at all Indianapolis area salons. Limit one per customer, valid on Fast level a. try x -Py equipment. See salon for more detalls. Expires 11/15/09. KRO959JAS 46032. r t nme ONAS ®s?:'' n t x la a 8� n a t FIRE w i e WITH PURCHASE o wITH THE PURCHASE of my OF 2 ENTREES 0 ENTREE AT REGULAR PRICE ottobetombinedemha otherghr. KRD959JASO Not to be combined withi mtAir afar. KRD9591AS N j 0 a o LUCK i so Iifi� e� p y a a Q t ai Works Includes: Expires 11130109- cc 44 s Bn ress Wash No ocran crwace FOR suv s, Y 8 P 4x45, VANS, OR PICKUPS. Clear Coat NOT VALID WfThJ OTHER COUPONS W s Wheat Bright do S U bH B R 15 Total aue *7771 1 1 o f I i Q ATTENTION CASHIER& Start this tape 07 -20 -09 RTUI, LP. f oil change ilher� x i •install new filter 9 x a e includes refill up to 5 quarts of premium motor oil x lubricate chassis (N applicable) '~s 1 free 14 point courtesy check The experience you wan. virth 1314 Range Line Road i OflerE ds coupna coupon c' i ,,55I89 Add52.50foroK so 2 fr 6�Ner ding f COYPlERA0l0 cut i KA09591AS-46032 4958A �S i a+an�rr (OEM m®QB IE OM MUM, AUM 00SUMM&E On Your3ide` WHEN YOU COMBIgE ®0TH YOUR HOME ARIA AUTO WITH" g !UTOILBF 6I$ /AIESS//OGIIRE/gB/EiHYE PLEASE CALL! o HASLA ESPANOL mum_ 1§ Y. eh�� I 0o0�� o'�" i dd �o d r v �p j M e j 40, s t Ilk