176783 09/02/2009 CITY OF CARMEL, INDIANA VENDOR: 360926 Page 1 of 1
ONE CIVIC SQUARE SHAVONNE HOLTON CHECK AMOUNT: $94.14
CARMEL, INDIANA 46032 3707 N MERIDIAN ST APT 3B
'ti o INDIANAPOLIS IN 46208 CHECK NUMBER: 176783
CHECK DATE: 9/212009
LCPARTMENT ACCOUNT PO NUMBER IN VOICE NUMBE AMOUNT DES CRIPTIO N
1046 4239039 41.89 GENERAL PROGRAM SUPPL
:1046 4343004 52.25 TRAVEL PER DIEMS
PRESCRIBED BY STATE BOARD Or ACCOUNTS GENERAL FORM NO. 101 (1986
MILEAGE CLA�IM�` L VA� *De
(GOVERNMENTAL UNPn ON ACCOUNT OF APPROPRIATION NO. FOR
(OFFICE. BOARD, DEPARTMENT OR INSI TUTION)
SPEEDOMETER AUTO )1II.E E
2 z FROM TO READING NATURE OF BUSINESS MILES C
POINT POINT START FINISH 1'AAVELED PEAS
1
r n-
r
r t
S n
r o
no n
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, the the amount claimed s e 11 d e, aft e alt wing all just credits
end that no part of t e same has been paid.
Date p
r1 i 2 009
Carmel o Clay
Parks &Recreation
Employee Expense Reimbursement Request
Date of Fund Account Account
Receipt Vendor listed on receipt Line Budget Description Amount Purpose of Expense
y i
f c0,
All receipts should be attached in the same order as listed above.
No sales tax will be reimbursed. TOTAL: L 9
Employee Name (print) shayo n n 2; AUG 6 2009
Addres n� r 1 1C�, (l
Check
4 v e
payable to: City, St, Zip n 0 Ij
Signature: s Approved by:
Date: ��0 Date: ()�J
Business Services Division, Revised 7 -7 -08
FILE: Shared\Administrative \Forms \Staff Forms \Employee Exp Reimb Request
INDIANAPOLIS STAGE SALES AND RENTALS, INC.
905 MASSACHUSETTS AVE. INDIANAPOLIS, IN 46202
317-635-9430 800-637-8243 Fax 317-635-9433
SALESPERSON: SALES RENTAL ORDER FORM DATE:
CUSTOMER: SHIP TCF
�Customer PO Ship \Aa:
I Contact: Phone
Need By, Fax:
QTY MFG. PART DESCRIPTION EACH TOTAL
1- 7
Ta)
Tot2
There Will be a 20% restocking fee on'all returned merchandise.
IRENTAL PICK UP RETURN EACH TOTAL__]
I
This Is a contract of renting only and not of sale. The undersigned renter agrees that he has rented the Item(s) herein described upon the express condition that It will
at all times remain the property of Indianapolis Stage: that he has examined said dem(s), found It to be In good condition and will return It In good condition as when he
received R, ordinary wear and tear Is excepted: that he will return at once to Indianapolis Stage and Item(s) not functioning normally: that he will pay promptly when due
all charges which accrue because of this rental, including damages to said Item(s). In the event the renter falls to return sold fiem(s) at the agreed time or falls to abide
by any of the other terms of this contract, Indianapolis Stage may repossess it without notice to the renter and Indianapolis Stage Is hereby released from all claims
arising there from. All charges are based on the time Item(s) Is In renter's possession whether In use or not. Indianapolis Stage Is not responsible for accidents or
injuries caused directly or Indirectly In the use of the rented Item(s).
SIGNATURE
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
7/31/09 Reimb. Mileage 6/29/09 7/30/09 52.25
7/31/09 Reimb. General program supplies 41.89
Total 94.14
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
94.14
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1046 Reimb. 4343004 52.25 i hereby certify that the attached invoice(s), or
1046 Reimb. 4239039 41.89 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
27 -Aug 2009
1
Signature
94.14 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund