178072 10/14/2009 i
CITY OF CARMEL, INDIANA VENDOR: 363400 Page 1 of 1
f JENNIFER BROSIUS ONE CIVIC SQUARE J
i; CHECK AMOUNT: $215.49
CARMEL, INDIANA 46032 10321 FOXWOOD DRIVE
INDIANAPOLIS IN 46280 CHECK NUMBER: 178072
CHECK DATE: 10/14/2009
DEPARTMENT A CCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1047 4358400 339936 215.49 REFUNDS AWARDS INDE
Z
000339936.Txt
0 @03ry &36.!x
Monon Center Clerk: RDG
Date: 09/24/2009 Time: 07:06:11
H /H: Jennifer Brosius
F /M: Jennifer Brosius
Description Ext Price
Pass 0 Type 59.51
Yly GF Res Unli
From 07/07/2009 0710712010
Rcpt# 339936 Prev Bal: 0.00
New charges 215.49
New Tax: 0.00
Total Due: 215.49
Tot Refund: 215.49
New Bal. 0.00 3=
Refund Type: Refund from Finance��
REFUND FINAN Refund of: 215.49
All refunds are subject to state Board
of Accounts claim procedure and may take
4 -6 weeks to proce A k will be
issued. ie —cii`sh or re 'rd refunds.
Authorized�signature Date
Authorized signature Date
Fed Tax ID #35- 6000972
oi l,
Rcpt# 339936
Dm
Page 1
Staff Initials:
The
M 0, In 4 u n1"k 0 e t 10" Date: 9
nt
FDC Initials:
AT CE 1 AL PF" R Date:
Pass Cancellation supervisor:
Date:
ECC_h �Refund� r H ousehold Credit (Circle One)
*Note: Check refunds take 3 4 weeks to process. Household credit will be placed on account for credit towards next transaction.
If you are canceling a monthly passport, you understand that you must give at least Mays prior notice to your next payment date.
Name requesting cancellation: s 0 5 1 u$ Phone Number:
Address: L City: ?.rj:aJF4"s Zip: Y4 0--S6
Passholder Name(s): _'j_tkW J T V��s r btS
Pass that you would like to cancel: Atf �r G uo Today's Date(s):
Reason for pass cancellation: 4% Yqjjalc Re,
Passholder's Signature: hubA c, r� 8 )r P Y r__
*Please turn into front Desk Coordinator
Amount Approved: Refund or Credit on Date: Reason:
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.
Brosius, Jennifer Terms
10321 Foxwood Drive Date Due
Indianapolis, IN 46280
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
9124109 339936 Refund 215.49
Total 215.49
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.
Brosius, Jennifer Allowed 20
10321 Foxwood Drive
Indianapolis, IN 46280
In Sum of
215.49
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT#1TITLE AMOUNT Board Members
Dept
1047 339936 4358400 215.49 1 hereby certify that the attached invoice(s), or
bi!I(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
7 -Oct 2009
Signature
215.49 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund