177695 09/29/2009 a" CITY OF CARMEL, INDIANA VENDOR. 131130 Page 1 of 1
ONE CIVIC SQUARE HINCKLEY SPRINGS
CARMEL, INDIANA 46032 CHECK AMOUNT: $43.34
PO BOX 6fi0579
'ti
DALLAS TX 75266 -0579 CHECK NUMBER: 177695
CHECK DATE: 9/29/2009
T DEP ARTMEN T A P NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4239099 2677859 43.34 OTHER MTSCELLANOUS
11INI:KI i tiu:i WAIEH
8w) rm -PURE
WA I LI I. COM
ORIGINAL
CUSTOMER 1722004 TICKER 092603042010
LOCATION 2677868 PO
CARME_L CITY COURT Date: 09117/2009 Time: 10:40:03 AM
1 CIVIC SO ROUTE #3042 DAVID
CARMEL, IN 46032
Last Payment Date: 1 19;14;2..109 last Payment Amount: 21.85
NI OdUC! Deliver ?d QIY PRICE AMOUNT($)
HS 5G DR NS 1 9.49 9.49
B01 S.OG PLS 1 6.00 6.00
BOT S.OG PLS -1 6.00 -6.00
(1 Buttles Delivered 1 Empty Oi)k les Returned 0 Butlles nelros;tedl
Subtotal Sales 9.49
Sales Tax 0.00
DELIVERY TICKET TOTAL 9.49
Previous Account Balance 31_98
Total Balance Due 41.47
Payrren t s 0.00
ENDING BALANCE 41.47
Next Delivery Date 1010112009
We bill monthly by summary Invuiee.
Retain for your records.
i ;I:KLEY SPRINGS WATER
I 800- 444-PURE
WATEH.COM
ORIGINAL
CUSIOMER 1722004 TICKET 092463042022
LOCATION 2677868 PO
CARMEL I;I WURI Dale: 09103!2009 Time: 10:55:33 AM
I CIVIC `;11 ROUTE #3042 DAVID
CARMEL, IN 46032
LAS 1. Pi n Last Payirrn!
Piuducl tlel ivy ,ed OTY PRICE AMOUNT($)
HS 5G OR NS 2 9.49 18.98
BOT 5.OG PLS 2 6.00 12.00
BOT 5.OG ;'I -2 6.00 -12.00
(2 Butots rl r Empty Duttlrs R0111ueJ 0 Do 1 fir;,,.�sited)
Subtotal Sales 18.98
Sales Tax 0.00
DELIVERY TICKET IDIAL 18.98
Previous Account Balance 34.85
Total Balance Due 53.83
Payments 0.00
ENDING BALANCE 53.83
Next Delivery Date 09/1712009
We bill munthly by summary Invoice.
Retain for your records.
1- 800-4- WATERS (492 -8377) www.H
r
Upcoming Delivery Dates
ndd
October November December Springs,
Bottled Water •Filtration •Coffee
Thursday, 1 Thursday, 12 Thursday, 10 We are proud to announce our new partnership with
Thursday, 15 Friday, 20 Thursday, 24 Susan G. Komen for the Cure! To celebrate this endeavor,
Thursday, 29 during the months of September and October you may notice
we've changed our 5- gallon bottles to a new pink cap to
show our commitment. Visit water.com for more information!
Customer Account 17220042677859
KIM ROTT Invoice Date: 09 -19 -09
CARMEL CITY COURT Invoice 0909 1722004 2677859
1 CIVIC SQ
CARMEL, IN 46032 Purchase Order M
Date Transaction Details Qty. Each Amount
Previous Balance 21.85
09 -14 -09 P176778 Payment Check 176778 Thank You -21.85
Remaining Balance 0.00
R092372494748 WHITE HOT AND COLD COOLER RENTAL 1.0 13.00 13.00
09 -03 -09 T092463042022 HINCKLEY SPRINGS 5G DRINK NON -SPILL 2.0 9.49 18.98
5.0 GAL BOTTLE RETURN -2.0 6.00
5.0 GAL BOTTLE DEPOSIT 2.0 6.00 12.00
Rec'd By:
09 -17 -09 T092603042010 HINCKLEY SPRINGS 5G DRINK NON -SPILL 2.0 18.98
5.0 GAL BOTTLE RETURN -1.0 c ffP -6.00
5.0 GAL BOTTLE DEPOSIT 2.0 12.00
Recd By:
09 -17 -09 45056344 ENERGY SURCHARGE 1.0 1.87 1.87
Total New Charges 58.83
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
products, check your next delivery, pay your bill and much more. Log on today)
30356- P -CC35
Previous Balance Payment Total New Charges o Pay This Amount
$21.85 r $21.85 $58.83 $58.83
Write the com plete account number on you check. Detach remittance and_mai1 with paym In the enclosed envelo To pay online go to HinckleySprings.com V
How to Read Your Statement —WATERS wr,° Important Monthly Promotions:
u Deliver! Register online for access to your
Delivery Calendar:
account. You can view and pay your bill,
Your scheduled deliveries for check delivery schedule and order
the next three months.
products all online.
Customer Account Number: Bottle Deposits:
For prompt service, please use this Highlights bottle deposits and returns.
number when referring to your account.
Easy to Pay:
Pay your invoice through the mail, online at
Summary: 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 r K, Mail Remittance With Payment To:
various products and transactions. Please detach remittance and mail
❑,r �i� using business envelope provided.
IIJJI.. Illllh ..ILhIIJd..11l.h�p 1 M.li Famlrt.n°e W6h P.y—
Important Monthly Message o.,da.i VIM iJI 1,1,1 11,1''1 11,11.111,11
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
You do not have to a amount in q uestion while we are investigating, but on your check gives us permission to debit your checking account electronically
p ay a q g. g 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 -0575.
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
Purchase Order No.
�oG45 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
�9 a� ;6 Zf V7
13.v
7
J
Total.3
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.
1 20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
Jam A IN SUM OF
6605 79-
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
13 0 1 A 37 29 5.3.3 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
200
41�4 1 44 A-,
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund