172239 05/13/2009 CITY OF CARMEL, INDIANA VENDOR: 362846 Page 1 of 1
ONE CIVIC SQUARE TOM BURCHILL
F CHECK AMOUNT: $166.37
CARMEL, INDIANA 46032 106 CARRIAGE HILL DR
MCMURRAY PA 15317 CHECK NUMBER: 172239
CHECK DATE: 5/13/2009
DEPARTMENT ACCOUNT PO N UMBER INVOICE NUMBE A MOUNT DESCRIPTION
1047 4358400 253357 166.37 REFUNDS AWARDS INDE
S
PASS REFUND RECEIPT
Receipt 253357
Payment Date: 04/27/2009
Household 23990
Home Phone: (317)727 -5880
Work Phone: (317)
TOM RCHIL Monon Center
522 E. 8T TREET Carmel IN 46032
I INDIANAPOLIS IN 46280
Phone: (317)848 -7275
Fed Tax ID #35- 6000972
Pass Details
CANCELLATION Refund Of 166.37
Pass Holder: Tom Burchill Fees Tax Discount Prev Paid QUr Paid Amount Due
Pass Type: Yly FT Alt Res (YFTAR), #52652 73.63 0.00 73.63 0.00 0.00
Valid Dates: 01/05/2009 to 01/05/2010 Pass Cancellation)
Fee Details: Fee Description Amount Cou Discount Sales Tax Total Fee
Yearly Fitness Adult 73.63 1.00 0.00 0.00 73.63
Cancel Reason: Moving to Pennsylvania
G/L C ade Descri Account Number Cst Cntr Descri Account Number Amount
999999 Control Account (AP) Enter Control Acct CNTRL Control Account (AP) Enter Control Acct here 166.37 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 04127/09 09:26:08 by CRB FEES CHANGED ON CANCELLED ITEMS 166.37
DISCOUNT APPLIED AGAINST CANCELLED FEES O 0.00
SALES TAX CHARGED ON CANCELLED FEES 0.00
NE iTiFAMOUNT%EROM?CANCELLEQ=ITEMS
TiOTAL;AMOUNT�REFUNDED'v;
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 166.37 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.
7-07
Autho ized Signature ate uthorized Signature Date
Page 1
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.
Burchill, Tom Terms
106 Carriage Hill Dr. Date Due
ti 1 McMurray, PA 15317
r
J
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
4/27109 253357 Refund 166.37
Total 166.37
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.
Burchill, Tom Allowed 20
106 Carriage Hill Dr.
McMurray, PA 15317
�r
In Sum of
166.37
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT#/TlTLE AMOUNT Board Members
Dept
1047 253357 4358400. 166.37 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
7 -May 2009
Signature
166.37 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund