178198 10/14/2009 CITY OF CARMEL, INDIANA VENDOR: 360926 Page 1 of 1
ONE CIVIC SQUARE SHAVONNE HOLTON
CARMEL, INDIANA 46032 3707 N MERIDIAN ST APT 3B CHECK AMOUNT: $12.65
INDIANAPOLIS IN 46208 CHECK NUMBER: 178198
CHECK DATE: 10/14/2009
DEPARTMENT ACCOUNT PO NUMBER IN NUMBER AMOUNT DESCRIPTION
1046 4343004 J 12.65 TRAVEL PER DIEMS
PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 101 0986
MILEAGE CLAoIMS(„ CA VQ n
(GOVERNMENTAL UNIT) ON ACCOUNT OF APPROPRIATION NO. FOR
(OFFICE, BOARD, DEPARTMENT OR INST[TIrnON)
SPEEDOMETER AUTO E
D((((((111������ FROM TO READING f NATURE OF BUSINESS MILES a
POINT POINT START FINISH )RAVELED PER MILE
n
i f) r
M an n e rc k
Lid r 1
AUTO LICENSE NO. TOTALS 23e 2 lS>J
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, I hereby certify that the foregoing account is just and correct, that the amount claime s a y e, aft lio g all just credits
and that rf of th same has been paid.
Date
CA
OCT G II1
1 2009
-4 0 1�-l�e
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.
360926 Holton, Shavonne Terms
8001 Canary Ln Apt A Date Due
Indianapolis, IN 46260
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
9/3/09 Reimb. Mileage 9/9 9/30/09 12.65
Total 12.65
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
i
Voucher No. Warrant No.
360926 Holton, Shavonne Allowed 20
8001 Canary Ln Apt A
Indianapolis, IN 46260
In Sum of
12.65
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1046 Reimb. 4343004 12.65 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 -Oct 2009
,1 2& y
Signature
12.65 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund