HomeMy WebLinkAbout168439 02/04/2009 CITY OF CARMEL, INDIANA VENDOR: 362498 Page 1 of 1
e J +RMf ONE CIVIC SQUARE REBECCA DEINER CHECK AMOUNT: $403.25
CARMEL, INDIANA 46032
CHECK NUMBER: 168439
CHECK DATE: 21412009
DEPARTMENT ACCOU PO NUMBER INVOICE -NUM AMOUNT DESCRIPTION
301 5023990' 403.25. OTHER EXPENSES
CITY OF CARM EL
A DOPTION ASSISTANCE CLAIM F ORM
SEE REVERSE SIDE FOR INFORMATION AND INSTRUCTIONS
Employee Name (First MI Last):
Department:
Social Security Number: Work Phone: 3'I`j Z� L4
Employee ID Number: 22- Home Phone: I Ct 1 Gj C 2 D
a a
Child's Name: A r lS 1 Y C' r`�' Date of Birth:
SSN (if known Final Adoption Date:
Attach copy of adoption decree if adoption has been finalized.
6
Date: Paid To: Services Rendered: Amount:
ef 7 Ai A,— C
=Lk LIT
c..`�.. `e`� C Y`. 'tom L�... i rte. c�1�i_;�
Attach original itemized receipts in U.S. dollars for all expenses listed above. No reimbursement will be made without appropriate documentation.
Attach separate sheet of paper for additional expenses.
o
I hereby o reqLest reimbursement for the adoption expenses listed above. By signing below, I certify that:
Check appropriate box: The child identified above has been placed in my home pursuant to adoption )�;or
The adoption of the child identified above has been finalized ;and
To the best of my knowledge, each expense listed above is a qualified adoption expense under the City of Carmel
Adoption Assistance Program; and
All statements and documentation relating to this claim are true and complete.
I understand that incomplete or inaccurate information may adversely affect my eligibility for benefits through the
Adoption Assistance Program.
Emplo ee i n t r Date: ll 11 C�
Form HR103 (1108) Official form cannot be altered or substituted.
Bysscrib0u� ACCOUNTS PAYABLE VOUCHER
State Board of Accounts City Form No. 201 (Rev. 1995)
t�
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
Rebecca S. Diener
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0112710 Adoption Assistance $403.25
$403.25
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 N127109— WARRANT NO.
Rebecca Diener ALLOWED 20
IN SUM OF
$403.25
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Funds Escrow
Board Members
PO# or
DEPT INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
Medical $403.25 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund