205409 01/17/2012 CITY OF CARMEL, INDIANA VENDOR: 027850 Page 1 of 1
0 ONE CIVIC SQUARE JAMES BRAINARD CHECK AMOUNT: $7,609.16
CARMEL, INDIANA 46032
CHECK NUMBER: 205409
CHECK DATE: 1/17/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 7,609.16 2010 2011 H INS REF
r
BRAINARD REFUND
2010 BW Medical BW Dental Total Paid /Payroll Prepaid /Check Overpaid REFUND
112.68 11.47 3,227.90 3,227.90 3,227.90 7,609.16
1/17/2012
2011 BW Medical BW Dental Total Paid /Payroll Prepaid /Check Overpaid
156.00 12.51 4,381.26 4,381.26 4,381.26
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
An invoice or 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.
ayee
W 'C l a Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill s))
S l LMI A .16
Total
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
obi �I�S
�u,
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
p 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
20
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund