170234 03/31/2009 CITY OF CARMEL, INDIANA VENDOR: T362687 Page 1 of 1
f ONE CIVIC SQUARE GREGORY GORSKI CHECK AMOUNT: $219.19
CARMEL, INDIANA 46032 13164 DERBYSHIRE CT
CARMEL IN 46032 CHECK NUMBER: 170234
CHECK DATE: 3/31/2009
DEPARTMENT AC COUN T PO NUM INVOI NUMBER AM OUNT D ESCRIPTION
1047 4358400 240853 219.19 REFUNDS AWARDS INDE
PASS REFUND RECEIPT
Receipt 240853
Payment Date: 03/18/2009
Household 16128
Home Phone: (317)848 -2511
Work Phone: (317)693 -2701
GREGORY GORSKI Monon Center
13164 DERBYSHIRE CT Carmel IN 46032
CARMEL IN 46032
Phone: (317)848 -7275
Fed Tax ID #35- 6000972
Pass Details
CANCELLATION Refund Of 219.19
Pass Holder: Gregory Gorski Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Yly AQ Alt Res (YAQAR), #21193 20.81 0.00 20.81 0.00 0.00
Valid Dates: 02/14/2009 to 02/18/2010 Pass Cancellation)
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
Yearly Aquatics Adul 20.81 1.00 0.00 0.00 20.81
Cancel Reason: Transferring to Monon Center Passport
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 219.19 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 HOUSEHOLD BALANCE 0.00
Processed on 03/18/09 13:37:18 by CRB FEES CHANGED ON CANCELLED ITEMS 219.19
DISCOUNT APPLIED AGAINST CANCELLED FEES 0.00
SALES TAX CHARGED ON CANCELLED FEES 0.00
NET AMOUNT-FROM CANCELLED ITEMS 219.19
TOTAL AMOUNT'REFUNDED 219.19
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 219.19 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.
Aut ed Signature Date A� uthorized Signature Date
Page #1
&L
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.
Gorski, Gregory Terms
13164 Derbyshire Ct Date Due
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
3118/09 240853 Refund 219.19
Total 219.19
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.
Gorski, Gregory Allowed 20
13164 Derbyshire Ct
Carmel, IN 46032
In Sum of
219.19
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1047 240853 4358400 219.19 1 hereby certify that the attached invoice(s), or
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
25 -Mar 2009
Signature
219.19 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund