179699 11/24/2009 CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
ONE CIVIC SQUARE HINCKLEY SPRINGS CHECK AMOUNT: $37.38
s' t CARMEL, INDIANA 46032 PO BOX 660579
DALLAS TX 75266-0579 CHECK NUMBER: 179699
CHECK DATE: 11/24/2009
DEPARTMENT ACCOUNT PO NUMBER INVO NUM A MOUNT DESCRIPTION
1301 4239099 2677859 37.38 OTHER MISCELLANOUS
HINCKLEY SPRINGS WATER
800-444 -PURE
WAIER.COM
ORIGINAL
CUSTOMER 1722004 TICKET 0931123042007
tUCATION 2677868 PO
CARMEL CITY COURT Date: 10129!2009 Time: 06:53:40 AM
I CIVIC SO ROUTE #3042 DAVID
CARMEL, IN 46032
Last Payment Dale: 10113/2009 Lest Payment Airuunt: 43.34
Product Delivered OTY PRICE AMOUNT($)
HS 5G OR NS 1 9.49 9.49
BOT 5.0G PLS 1 6.00 6.00
BOT 5.OG PLS -2 6.00 -12.00
(I DVllles Delivered 2 51 11ty Dultics Retunied -1 Duffles Dupusited)
Subtotal Sales 3.49
Sales Tax 0.00
DELIVERY TICKET TOTAL 3.49
Previous Account Balance 46.89
Total Balance Due 50.38
Payments 0.00
ENDING BALANCE 50.38
We bill monthly by summary Invuice
Retain for your records.
Next Delivery Date 11/12/2009
We b i l l uuntlily by summary Invoice.
Retain for your records.
HINCKLEY "Pik dAi
800-44! t
WAIER. Clim
ORIGINAL
CUSTOMER 17221.104 IICKEI 1193163042015
LOCATION 2677868 PO
CAwi CITY COURT Date: 1111212009 Time: 09:36:05 AM
1) I CIVIC SO ROUTE #3042 DAVID
CARMEL, IN 46032
Last Payment Date: 11109120119 Last P:ryirent Amount: 18.4
Product Delivered QTY PRICE AMOUNT($)
HS 5G DR NS 2 9.49 18.98
BOT 5.OG PLS 2 6.00 12.00
BOT 5.OG PLS -2 G.00 12.00
(2 Dottie, nvli recd 2 i ty n ttirs lie tinner! n Dotll:v nelu i-
Subtotal Sales 18.98
Sales Tax 0.00
DELIVERY TICKET TOTAL 18.98
Previous Account Balance 31.98
Total Balance Due 50.96
Payments 0.00
ENDING BALANCE 50.96
We bit l muWl ly by suu'anary Invoice
Retain for your recurds.
N„ very hate 1211012009
Wl y by swwi.vy !n:uice-
i yuk; f,.—cwids.
1- 800 -4- WATERS 492 -8377 www.Hinckley5p ings.co m
Upcoming Delivery Dates`.
inckl W
November December January Spnngs,,
f Bottled Water •Filtration •Coffee
Friday, 20 Thursday, 10 Thursday, 7 Help us make a difference in the fight against breast
Thursday, 24 Thursday, 21 cancer. Now through December 31, 2009, when you refer your
friends or family to start new service with any one of our
Komen Budget Plans, we'll donate $30 to Susan G. Komen for
the Cure. Visit Water.com /KomenReferral today!
Customer Account 17220042677859
KIM ROTT Invoice Date: 11 -14 -09
CARMEL CITY COURT Invoice M 1109 1722004 2677859
1 CIVIC SQ
CARMEL, IN 46032 Purchase Order
Date Transaction Details Qty. Each Amount
Previous Balance 33.89
11 -09 -09 P178714 Payment Check 178714 Thank You -18.40
Remaining Balance 15.49
R092932494748 WHITE HOT AND COLD COOLER RENTAL 1.0 13.00 13.00
10 -29 -09 T093023042007 HINCKLEY SPRINGS 5G DRINK NON -SPILL 1.0 9.49 9.49
5.0 GAL BOTTLE RETURN -2.0 6.00 -12.00
5.0 GAL BOTTLE DEPOSIT 1.0 6.00 6.00
Recd By: Not Available or Refused
11 -12 -09 46815424 ENERGY SURCHARGE 1.0 1.91 �1.91�
11 -12 -09 T093163042015 HINCKLEY SPRINGS 5G DRINK NON -SPILL 2.0 9.49
5.0 GAL BOTTLE RETURN -2.0 6.00 -12.00
5.0 GAL BOTTLE DEPOSIT 2.0 6.00 12.00
Recd By: Not Available or Refused
Total New Charges 37.38
Managing your account is now at your fingertips. Take advantage of many time saving
options available on water.com. Save paper when you sign up for elnvoice, order additional
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T� �,��87
Previous Balance Payment Total New Pay This Amount $33.89 $18.40 $37.
Write the complete accountnumber_on.your -check Detach.remittance and mail with.payment in_the.enclosed.envelope Lc pay online ,go.to_www.Hinckley8prings.com 4
How to Read Your Statement Important Monthly Promotions:
^m ^9DP11Ve �aPS sf, we oervert Register online for access to you!
Delivery Calendar: a account. You can view and pay your bill,
Your scheduled deliveries for 12 check delivery schedule and order
the next three months. products all online.
Customer Account Number: .a
For prompt service, please use this Bottle Deposits:
number when referring to your account. Highlights bottle deposits and returns.
Easy to Pay:
Pay your invoice through the mail, online at
Summary: a www.water,com or call us to expedite your
Previous balance and posted remittance with automatic credit card payments
payments since last bill.
Total New Charges:
This information provides totals for Mail Remittance With Payment To:
various products and transactions. wd, -a.. Please detach remittance and mail
w c, �ea•,q- using business envelope provided
Important Monthly Message
Billing Rights Summary Electronic Funds Transfer Notice
In case of Errors or Questions About Your Bill: If you pay by check, it will be converted into an "Electronic Funds Transfer"
If you think your bill is incorrect, or if you need more information about a (EFT), a process in which your financial institution is electronically instructed to
transaction on your bill, write us as soon as possible on a separate sheet, at transfer funds from your account to ours in lieu of processing the check. By
P.O. Box 660579, Dallas,TX 75266 -0579. We must hear from you no later sending your completed check to us, you authorize us to use the account
than 60 days after we sent you the first bill on which the error or problem information therein to create an EFT for the amount indicated on the check. If
appeared. Your bill shall be deemed correct unless disputed within 60 days the EFT cannot be processed for technical or other reasons, you authorize us
from receipt. You can telephone us, but doing so will not preserve your rights- to process an image replacement document, draft, or copy of your check.
In your letter, give us the following information: OPT OUT NOTICE: if you do not wish to participate in this check conversion
program, please write to us on a separate sheet at:
Your name and complete account number. P.O. Box 660579, Dallas, TX 75266 -0579.
The dollar amount of the suspected error.
Describe the error and explain why you believe there is an error. If you need Insufficient Funds Notice
more information, describe the item you are unsure about. If your check is returned for insufficient or uncollected funds (NSF), your signature
on your check gives us permission to debit your checking account electronically
You do not have to pay any amount in question while we are investigating, but for the uncollected amount. Payment by check constitutes your acceptance of
you are still obligated to pay the amount of your bill that is not in question. While these terms.
we investigate your questions, we cannot report you as delinquent or take any
action to collect the amount you question.
We appreciate your business.
As a food product, bottled water is subject to rules and regulations promulgated by the Federal Food and Drug Administration (FDA).
For further information, please write DS Waters of America, Inc. at P.O. Box 660579, Dallas, TX 75266 -0579.
Prescribed by 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
�A"J' Purchase Order No.
d;L jo (n ��79 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
1 3-00
/.9/
9.9(?
3. 1
Total 'k3 7 3Y
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 NO. WARRANT NO.
ALLOWED 20
IN SUM OF
73 Y
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
J ,3o j 5 39 �q 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 0 j
ign u
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund