205517 01/17/2012 CITY OF CARMEL, INDIANA VENDOR: 174450 Page 1 of 1
ONE CIVIC SQUARE ROGER KILBURN
�~z CARMEL, INDIANA 46032 17717 WILLOW CREEK WAY CHECK AMOUNT: $2,920.12
WESTFIELD IN 46074 CHECK NUMBER: 205517
CHECK DATE: 1/17/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 2,920.12 H INS REFUND
January 20, 2012
Roger Kilburn
16967 Southall Drive
Westfield, IN 46074
Roger:
As I told you by phone last week, I have received a copy of your PERF disability appeal. Based
on the fact that PERF is granting you a Class 2 disability, retroactive to your retirement date of
December 24, 2010, we will also adjust your insurance premiums back to that date.
I am enclosing a refund of $2,920.12, which is 50% of the $588.84 monthly premium for
February through December 2011, minus the premium due for January 2012.
$3,238.62 $588.84 x 50% x 11 months
-$318.50 less January 2012 premium now due
$2,920.12 TOTAL REFUND
You are now eligible for the City to pay 50% of your monthly premium, up to a maximum of
$700.00. Your 2012 monthly medical premium is $637.00, of which you will pay $318.50.
Your next payment of $318.50 will be due February 1, 2012.
If you wish to add dental coverage, you must wait until the 2013 open enrollment period at the
end of 2012. If you get married this year, you can add your wife as of your wedding date,
provided you submit the required enrollment form within 30 days after the event. The City's
contribution to your retiree /spouse premium is also capped at $700.00 per month.
I am pleased that we have reached a resolution in your case and can move forward. You know
how to get in touch with me. Please let me know if I can be of any further assistance.
Sincerely,
Barbara A. Lamb
Director of Human Resources
cc: Assistant Fire Chief David Haboush
Deputy Clerk Treasurer Cindy Sheeks
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.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attac ed invoice(s) or bill(s))
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.
C OLA ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
I
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
�Z D 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
r
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund