173781 06/24/2009 CITY OF CARMEL, INDIANA VENDOR: 362964 Page 1 of 1
ONE CIVIC SQUARE CHARMAINE COTA CHECK AMOUNT: $178.19
CARMEL, INDIANA 46032 8181 ROSEMEAD LANE
o a INDIANAPOLIS IN 46240 CHECK NUMBER: 173781
CHECK DATE: 6/24/2009
DEPARTMENT A PO NUMBER INV OICE NUMB AMOUNT DESCRIPTION
1047 4358400 178.19 REFUNDS AWARDS INDE
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PASS REFUND RECEIPT
7", c
Receipt 270251
Payment Date: 06/06/2009
Household 9078 JUN 0 8 2009 J
Home Phone: (317)802 -1669
Work Phone: (317)
y�
i CHARMAINE COTA Monon Center
8181 ROSEMEAD LANE Carmel IN 46032
INDIANAPOLIS IN 46240
Phone: (317)848 -7275
Fed Tax ID #35- 6000972
Pass Details
CANCELLATION Refund Of 178.19
Pass Holder: Charmaine Cota Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Seas AQ HH Res (SAQHR), #69680 26.81 0.00 26.81 0.00 0.00
Valid Dates: 05/23/2009 to 09/07/2009 Pass Cancellation)
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
Seas Aqua HH Res 26.81 1.00 0.00 0.00 26.81
Cancel Reason: The facility is too big for him to manage the kids
CANCELLATION
Pass Holder: Lily Cota Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Seas AQ HHAddR (SAQHRADD), #69681 0.00 0.00 0.00 0.00 0.00
Valid Dates: 05/23/2009 to 09/07/2009 Pass Cancellation)
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
Seas Aqua HH Add R 0.00 1.00 0.00 0.00 0.00
Cancel Reason: The facility is too big for him to manage the kids
I
CANCELLATION
Pass Holder: Jack Cota Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Seas AQ HHAddR (SAQHRADD), #69682 0.00 0.00 0.00 0.00 0.00
Valid Dates: 05/23/2009 to 09/07/2009 Pass Cancellation)
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
Seas Aqua HH Add R 0.00 1.00 0.00 0.00 0.00
Cancel Reason: The facility is too big for him to manage the kids
Page #f
PASS REFUND RECEIPT
Receipt# 270251
Payment Date: 06/06/2009
Household 9078
CANCELLATION
Pass Holder: Jim Cota Fees Tax Discount Prev Paid Cur Paid Amount Due
,Pass Type: Seas AQ HHAddR (SAQHRADD), #69683 0.00 0.00 0.00 0.00 0.00
Valid Dates: 05/23/2009 to 09/07/2009 Pass Cancellation)
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
Seas Aqua HH Add R 0.00 1.00 0.00 0.00 0.00
Cancel Reason: The facility is too big for him to manage the kids
CANCELLATION
Pass Holder: Abby Cota Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Seas AQ HHAddR (SAQHRADD), #69684 0.00 0.00 0.00 0.00 0.00
Valid Dates: 05/23/2009 to 09/07/2009 Pass Cancellation)
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
Seas Aqua HH Add R 0.00 1.00 0.00 0.00 0.00
Cancel Reason: The facility is too big for him to manage the kids
CANCELLATION
Pass Holder: Grace Cota Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Seas AQ HHAddR (SAQHRADD), #69685 0.00 0.00 0.00 0.00 0.00
Valid Dates: 05/23/2009 to 09/07/2009 Pass Cancellation)
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
Seas Aqua HH Add R 0.00 1.00 0.00 0.00 0.00
Cancel Reason: The facility is too big for him to manage the kids
G/L Code Description Account Number Cst Cntr Description Account Number Amount
999999 Control Account (AP) Enter Control Acct CNTRL Control Account (AP) Enter Control Acct here 178.19 DR
The REVENUE account was DEBITED and the CONTROL account was CREDITED on the day of the refund.
Finance will have to DEBIT the CONTROL account for the amounts listed above after the checks have been written to the customers.
PREVIOUS NET CREDIT HOUSEHOLD BALANCE 7.13
Processed on 06/06/09 17:19:54 by RDG FEES CHANGED ON CANCELLED ITEMS 178.19
DISCOUNT APPLIED AGAINST CANCELLED FEES 0.00
SALES TAX CHARGED ON CANCELLED FEES 0.00
NETAMOUNT'FROM?CANCELLED.ITEMS 17819
TOTAL'AMOUNT'REFUNDED 178.19
NEW NET CREDIT HOUSEHOLD BALANCE 7.13
Page 2
PASS REFUND RECEIPT
Receipt 270251
Payment Date: 06/06/2009
Household 9078
Refund of 178.19 Made By REFUND FINAN With Reference
All refunds are subject to State Board of Accounts claim procedure and may take 4 -6 weeks to process. A check will be
;issued. No cash or credit card refunds.
(0
Authorized Signature Date ,Xlhor'fz4d Signature Date
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Page 3
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.
Cota, Charmaine Terms
8181 Rosemead Lane Date Due
Indianapolis, IN 46240
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
6/6/09 270251 Refund 178.19
Total 178.19
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. Warrant No.
Cota, Charmaine Allowed 20
8181 Rosemead Lane
Indianapolis, IN 46240
In Sum of
178.19
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT#fTITLE AMOUNT Board Members
Dept
1047 270251 4358400 178.19 1 hereby certify that the attached invoice(s), or
biil(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
18 -Jun 2009
Signature
178.19 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund