178714 10/28/2009 CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
ONE CIVIC SQUARE HINCKLEY SPRINGS
to CARMEL, INDIANA 46032 CHECK AMOUNT: $18.40
PO BOX 660579
DALLAS TX 75266 -0579 CHECK NUMBER: 178714
CHECK DATE: 10/28/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4239099 100917220042 18.40 100917220042677859
HI NICK LEY SI'HINGS WATER
800
WAIER.COM
ORIGINAL
CUSTOMER 1722004 IICKET 092743042006
LOCATION 2677868 PO
CARMEL CITY COURT Dale: 10 /01 /20119 Time: 08:31:08 AM
1 CIVIC SO ROUTE #3042 DAVID
CARMEL, IN 46032
L:,st=B:,yirent Bate: 09114/2009 1 -41st Payren( Aurnunl: 21.85
Product Delivered OlY PRICE AMOUNT($)
HS 5G DR NS 1 9.49 9.49
BOT 5.uG PLS 1 6.00 6.00
BOT 5.OG PLS -1 6.00 -6.00
0 %ttles 19,divried 1 Empty Dull l, Reluine,l 0 Bottles Deposited)
Subtotal Sales 9.49
Sales Tax 0.00
DELIVERY IICKET TOTAL 9.49
Pieviuus Account Balance 71.83
Total Balance Due 81.32
Payments 0.00
ENDING BALANCE 81.32
Next Delivery Dale 10115/2009
t We bill monthly by suimnary Invoice.
Retain for your records.
IIINi;K1.1 Y .;i11iNUS WATER
800 444 -PURE
WAI ER. COM
ORIGINAL
CUSTOMER 1722004 IICKFI +7: 092883042017
LOCATION a 2677868 POa:
CARMEL 1 :11Y COURT Date: 1111151211119 Time: 10:34:49 AM
1 CIVIC SO ROUTE «3042 GARY
CARH, L, IN 46032
Pay ,.o t Date: 10/13/2009 Last Payment Wrvun L 43.34
Product Delivered MY PRICE AMOUNT($)
HS 5G DR NS 1 9.49 9.49
BOT 5.013 PLS 1 6.00 6.00
BOT 5.OG PLS -1 6.00 -6.00
(1 Dullles Dci�,,•J 1 Fupty Duitles D,;•luiued 0 Doit It: i Oepusiled
Subtotal Sales 9.49
Sales Tax 0.00
DELIVERY IICKET TOTAL 9.49
Previous Account Balance 37.98
Total Balance Due 47.47
Payments 0.00
ENDING BALANCE 47.47
Next Delivery Date 10129/2009
We bill monthly by suurnary Invoice.
Retain fur your records.
1- 8 00-4- WATERS 492 -8377 www.HinckleySprings.com
Upcoming Delivery Dates
October November December Spnng�
Bottled Water Filtration •Coffee
Thursday, 29 Thursday, 12 Thursday, 10 Help us make a difference in the fight against breast
Friday, 20 Thursday, 24 cancer. Now through October 31st, 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: 10 -17 -09
CARMEL CITY COURT
1 CIVIC SQ Invoice 1009 1722004 2677859
CARMEL, IN 46032 Purchase Order
Date Transaction Details Qty. Each Amount
Previous Balance 58.83
10 -13 -09 P177695 Payment Check 177695 Thank You -43.34
Remaining Balance 15.49
R092652494748 WHITE HOT AND COLD COOLER RENTAL 1.0 13.00 13.00
10 -01 -09 T092743042006 HINCKLEY SPRINGS 5G DRINK NON -SPILL 1.0 9.49 .49
5.0 GAL BOTTLE RETURN -1.0 6.00 -6
5.0 GAL BOTTLE DEPOSIT 1.0 6.00 6.00
Rec'd By:
10 -15 -09 T092883042017 HINCKLEY SPRINGS 5G DRINK NON -SPILL 1.0 9.49 .49
5.0 GAL BOTTLE RETURN -1.0 6.00 6.
5.0 GAL BOTTLE DEPOSIT 1.0 6.00 6.00
Rec'd By:
10 -15 -09 45947620 ENERGY SURCHARGE 1.0 1.91 1�
10 -15 -09 228366260 HINCKLEY SPRINGS 5G DRINK NON -SPILL -1.0 9.49 -9.49
5.0 GAL BOTTLE RETURN -1.0 6.00 -6.00
Total New Charges 18.40
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30356 -P -0035
Previous Balance Payment Total New Charges r� Pay This Amount
$58.83 $43.34 $18.40 $33.89
q Write the complete account number_on.your check Detach remittance and mail with payment,in the_enclosed envelope To, pay online, go -to _wwwAinckley.Spnggs.00m
How to Read Your Statement mpo nt Monthly Promotions:
Register online for access to your
uoonum.Ynucanwowuoupoyyo"'bm
De li v ery Ca check d�|,r�schedule and o�e,
Y— ----i'--- products all online.
Cus Bottle Deposits:
number when referring to your account. OMMUMU11
"e=="""" Highlights bottle deposits and returns,
p aym e nts 777 N Easy to Pay:
ay your
invoice through the mail, online at
Previous balance and posted remittance with automatic credit card payments
T ota l Ne C Mail Remittance With Payment To:
various products and transactions. Please detach remittance and mail
using business envelope provided.
Important Monthly Message
Billing Rights Summary Electronic Funds Transfer Notice
m case of Errors nr Questions About Your Bill: If you pay by check, it will bv converted into on "Electronic Funds Transfer"
/f you think your bill iv incorrect, o,n you need more information about a (EFT).a process m which your financial institution |s electronically instructed tn
transaction on your bill write us as soon as possible nna separate sheet, m transfer funds from your account to ours in lieu or processing the choox/By
pO. Box OOOorV We must hear from you nolater sending your completed check to vv you authorize uum use the account
than oO days after wn sent you the first bill on which the error o,problem information therein to create an EFT for the amount indicated on the check. n
appeared. Your bill shall bo deemed correct unless disputed within 8Odays the EFT cannot bo processed for technical vr other reasons, you authorize un
from receipt. You can telephone us, but doing sn will not preserve your rights. m process mn image replacement document, draft, u, copy o/ your check
|n your letter, give vs the following information: OpTOUTmOT|Cs:xyouuwnot`wow part
conversion p,ogm. p/oano write to vu on a separate sheet oc
Your name and complete account number. P.O. Box eooary Dallas, TXro2eV'nor9.
The dollar amount o/ the suspected e,mr-
Describe the error and explain why you believe there ioan error. x 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 electronicall
You un not have to pay any amount in question while we are investigating but for the uncollected amount. Payment uy check constitutes your acceptance vf
you are still obligated m pay the amount m your bill that io not mquestion, While these terms.
we investigate questions, we cannot report you as delinquent m take any
action m collect the amount you question
We appreciate your business.
xynfood product, bottled water iusubject to rules and mQu|momnm pmmu|oetou by the peuen,| Food and omQ 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 ACCOUNTS PAYABLE VOUCHER City Form No. 203 (Rev. 3995)
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
i Purchase Order No.
J D lo �Q 57 9 Terms
'O S 7 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0' k 9 09
r V oq,t o '7 A
100 1 7 UM4 -OG
10 0� y�
Total 3 �q
I 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
Cierk Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
.301 Ivo9 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
a (P 200
do j
Si nat re
Cost distribution ledger classification if t e
claim paid motor vehicle highway fund