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HomeMy WebLinkAbout176667 09/02/2009 CITY OF CARMEL, INDIANA VENDOR: 00353333 Page 1 of 1 0 ONE CIVIC SQUARE JEAN BELCHER CHECK AMOUNT: $17.06 CARMEL, INDIANA 46032 CHECK NUMBER: 1.76667 CHECK DATE: 912/2009 D EPARTMENT AC PO N UMBER INVOICE NUMB AMOUNT DESCRIPTION 1701 4343004 REIMB 17.06 TRAVEL PER DIEMS y se7s ^a Prescribed by State Board of Accounts General Form No. 101 (19 MILEAGE CLAIM TO DR. (Gov rnmental Unit) On Account of Appropriation No. for (Office, Board, Department or Institution) DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE @�5 20 ©q Point Point Start Finish TRAVELED PER MILE 1 3--D 9 —(3 73 W S 8 3 Auto License No. TOTALS 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 k 1 1; e l ez 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 required by law; That it is based upon statutory authority; That it is apparently correct U 4o incorrect On Account of Appropriation No. 7 �7 for Disbursing Officer Allowed g /��o 20 (D I �e 0 r in the sum of (Q 0 Q U O (D m 1 .7 1 0 �in9 (Board or Commission) R. o (D FILED o s O o Q n cn (D ;L (Official Title) C N N O 0 (D