205983 01/31/2012 CITY OF CARMEL, INDIANA VENDOR: 00350917 Page 1 of 1
ONE CIVIC SQUARE KIM ROTT CHECK AMOUNT: $25.10
z�o CARMEL, INDIANA 46032
CHECK NUMBER: 205983
CHECK DATE: 1/3112012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4343004 REIMB 25.10 TRAVEL PER DIEMS
Prescribed by State Board of Accounts M ILEAGE �p General Form No. 101 (1955)
MILEAGE CLAIM
TO DR.
(Governmental Unit)
On Account of Appropriation No. y -30.0 `7 for it c Q C.
(Office, Board, Depart ment or Institution)
DATE FROM TO
ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE
201 Point Point Start Finish TRAVELED PER MILE
Auto License No. TOTALS 7 10
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 I -11
Q
QQ ��as Warrant No. I have examined the within claim and
ms hereby certify as follovas:
TN FAVOR OF
That it is in proper form;
y 's b That it is duly authenticated as required
by law;
y. That it is based upon statutory authority;
rbo ��`�6 -yam That it is apparently correct
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for
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Disbursing Officer
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M the sum of
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
MA
Total Of)
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.
ALLOWED 20
IN SUM OF
0 c)
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE MOUNT
DEPT. I 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
20
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund