177700 09/29/2009 CITY OF CARMEL, INDIANA VENDOR: 360926 Page 1 of 1
ONE CIVIC SQUARE SHAVONNE HOLTON CHECK AMOUNT: $23.65
CARMEL, INDIANA 46032 3707 N MERIDIAN ST APT 3B
INDIANAPOLIS IN 46208 CHECK NUMBER: 177700
CHECK DATE: 9/29/2009
DEPARTMENT ACCOUNT PO NUMBER IN VOICE NUMBER A MOUNT DESCRIPTION
1046 4343004 REIMB 23.65 TRAVEL PER DIEMS
PRE-SCRIBED BY STATE BOARD OF ACCOUNTS
GENERAL FORM 110. 10) (1966)
MILEAGE CLAIM- ')0rV Cn�lC1G
(GOVERNMENTAL UNIT7
ON ACCOUNT OF APPROPRIATION NO. FO
(OF1CL, BOARD, DLPARTMZNT OR 1NSTMJTION)
SPEEDOMETER
DATE FROM TO READING AMILfi3 MILEAGE 511 C
NATURE OF BUSINESS
2� POINT POINT START FINISH TRAVELED PER
r
In v- tiq oz
5
n
r
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, I hereby certify that the foregoing account is just and correct, that the amount claim s q 11 dve fter liowinq all just credits
end thel ng part of Jhe s me has been paid.
Date 0
SEP 0 3 2009
ACCOUNTS PAYABLE VOUCHER
A 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
8/31/09 Reimb. Mileage 8/6/09 8/25/09 23.65
Total 23.65
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
i 23.65
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1046 Reimb. 4343004 23.65 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
24 -Sep 2009
Signature
23.65 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund