179145 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: 363569 Page 1 of 1
ONE CIVIC SQUARE MICHAEL CALVERT CHECK AMOUNT: $23.10
CARMEL, INDIANA 46032 C/O BROOKSHIRE GOLF COURSE
CHECK NUMBER: 179145
CHECK DATE: 11/11/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 23.10 TRAVEL PER DIEMS
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Prescribed by State Board of Accounts pppp AA CC pp pp//�� General Form No. 101 (1955)
'Itl1�6.SH�� C�/1�.Id1
TO ��1 �C f`T Zr/L GIL61� DR.
(Governmental Unit)
i 0k' On Account of Appropriation No. for
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING" NATURE OF BUSINESS AUTO MILES MILEAGE S
20 Point Point Start Finish TRAVELED PER MILE
A- w QZ f 9 L c,u ei *ls �2�s
o q o 0 So
U cc S z of 0 O
(D Z r 0'7 9 7L l ZC p
I E li
Auto License No.M TOTALS a /Q
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter.155, Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
Date /e' 30 -0 9
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon statutory autho
3, O That it is apparently correct
incorrect
On Account of Appropriation No. for
Disbursing Officer
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(Board or Conunission)
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