178724 10/28/2009 CITY OF CARMEL, INDIANA VENDOR: 361054 Page 1 of 1
ONE CIVIC SQUARE CHARLES A IMAN
CARMEL, INDIANA 46032 11018 TAM C'SHANTER DR CHECK AMOUNT: $50.05
CARMEL IN 46032 CHECK NUMBER: 178724
CHECK DATE: 10/28/2009
DEPARTMENT ACCOUNT PO NUM IN VOICE NUMBER AMOUNT DESCRIPTION
1046 4343004 REIMB 50.05 TRAVEL PER DIEMS
t
PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 101 (1986)
MILEAGE CLAIM
TO
(GOVERNMENTAL UNIT) ON ACCOUNT OF APPROPRIATION NO. FOR
(OFFICE, BOARD, DEPARTMENT OR INSTITUTION)
SPEEDOMETER
DATE
FROM TO READING AUTO MILEAG
NATURE OF BUSYNESS MILES
19 ]ate(
PO POINT START FINISH TRAVELED
p MILE 7'
�f
9
E i
f0 uL i 1 10 09
0
AUTO LICENSE NO. TOTALS 1� k
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map, 05
�ss �s
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, I hereby certify that the foregoing account is just and c rrect, that the amount claimed is legall ue, o- g all just credits,
end that no papt of/the same has been paid.
Dane d �w o� �f Lf
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.
361054 Iman, Charles Terms
Date Due
ti
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
10/8/09 Reimb. Mileage 9/10 9/30/09 50.05
Total 50.05
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
L 10
Voucher No. Warrant No.
Iman, Charles Allowed 20
361054
In Sum of
50.05
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT#ITITLE AMOUNT Board Members
Dept
1046 Reimb. 4343004 50.05 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
22 -Oct 2009
Signature
Is 50.05 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund