169766 03/17/2009 0i CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
ONE CIVIC SQUARE HYLANT GROUP CHECK AMOUNT: $25,194.25
CARMEL, INDIANA 46032 P o Box 1910
CARMEL IN 46082 CHECK NUMBER: 169766
CHECK DATE: 3/17/2009
C JEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
302 5023990 684222 25,194.25 OTHER EXPENSES
Eff Date Trn Type Policy Description Amount
p INVOICE 684222
t
01/01/09 NIS WC -S WCX002730 4/1/09, 2 of WC Insts Citizens Ins Co of America S 14,056.75
01/01/09 NIS WC -S WCX002730 4/1/09, 2 of TPA tits Citizens Ins Co of America 11,137.50
Invoice Balance: 25,194.25
HYLANT GROUP www.hylant.com
501 Congressional Blvd Suite 300 P.O. Box 1910 Carmel, IN 46032 Local: 317 817 -5000 Fax: 31.7- 817 -5151
1, .scribed �y State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
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
Hylant Group Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
(YA In I Ina
684222 4/1109, 12r_ of 4 WC hists (CMI) 14,056.75
1, 137.50
Total
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 I`MMB109_WARRANT NO.
�-4 Hy Group ALLOWED 20
Box 1910 IN SUM OF
C arm el, IN 413-08-
$25,194.25
ON ACCOUNT OF APPROPRIATION FOR
302 FUND
Board Members
PO# or
DEPT INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify that the attached invoice(s), or
1205 684222 302 $25 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
S Y 0 ture
T
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund