176778 09/02/2009 CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
ONE CIVIC SQUARE HINCKLEY SPRINGS CHECK AMOUNT: $21.85
s..�o CARMEL, INDIANA 46032 PO BOX 660579
DALLAS TX 75266 -0579 CHECK NUMBER: 176778
CHECK DATE: 912/2009
DEPA ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
-1301 4239099 2677859 21.85 OTHER MTSCELLANOUS
HINCKLEY SPRINGS WAIER
800- 444-PURE
WAIER.COM
ORIGINAL
CUSTOMER a 1722004 TICKET 092323042008
LOCATION 2677868 PU
CARMEL CITY I,IIURI Date: 08120!21109 Time: 08:41:12 AM
1 CIVIC SO ROUTE #3042 DAVID
CARMEL, IN 46032
Last Payirent mile: otm i 2nn9 Last Payment Amount: 52.72
Product Delivered MY PRICE AMOUNT($)
HS 5G OR NS 2 9.49 18.98
BOT 5.OG PLS 2 6.00 12.00
BOT S.OG PLS -2 6.00 -12.00
(2 D'1ltIeS Or.live;MI 7 Fu;I iy ll t I?,t I n Dot!1, 11.;I osiled
Subtotal Sales 18.98
Sales lax 0.00
I11:1;VI:HY 1lCKt:I ILIUM 18.98
Pnrr ious Account Da Lucre 1.00
ro L,l Balance Due 19.98
PaY-rents 0.00
ENDING BALANCE 19.98
Next Delivery Dale 0910312009
We bill monthly by suic -ary Invoice.
Retain for your records.
RSR Siynature Checker Signature
HINCKLEY SPRINGS WATER
800- 444 -PURE
WATER.COM
ORIGINAL
CUSTOMER 17220114 TICKET 092183042007
LOCATION 2677868 POW:
CARMEL CITY COURT Date: 11810612009 Time: 08:34:27 AM
i CIVIL' SO ROUTE #3042 DAVID
CARMEL, IN 46032
Last Pnyirent Date: 06131112009 Last Payment Wnount: 43.23
Product Delivered MY PRICE AMOUNT($)
BOT 5.0G PI -S -2 6.00 -12.00
(0 Dp((I„ Drliv- el 2 Gr; ly T1;(Ilr., Rr.luini «I -2 D,w b Depusiterl)
Subtotal Sales -12.00
Sales Tax 0.00
DELIVERY IICKEI IOIAL -12.00
Previous Account Balance 65.72
Total Balance Due 53.72
Payments 0.00
ENDING BALANCE 53.72
Next Delivery Date 08/2012009
We bill munthly by swoirary Invuice.
Retain for your records.
1- m
Upcoming Delivery Dates IV
erl
September October November Springs Bottled Water Filtration Coffee
Thursday, 3 Thursday, 1 Thursday, 12 Put a smile on your employees' faces by starting your office
Thursday, 17 Thursday, 15 Friday, 20 coffee service. From single -serve coffee machines to energy
Thursday, 29 saving commercial brewers, we will provide you with the
perfect selection of equipment and products to brew the
p erfect cup. Call us today to start your servicel
Customer Account M 17220042677859
KIM ROTT Invoice Date 08 -22 -09
CARMEL CITY COURT Invoice 0809 1722004 2677859
1 civic SQ
CARMEL, IN 46032 Purchase Order
Date Transaction Details Qty. Each Amount
Previous Balance 52.72
08 -11 -09 P175727 Payment Check 175727 Thank You -52.72
Remaining Balance 0.00
8092092494748 WHITE HOT AND COLD COOLER RENTAL 1.0 13.00 13.00
08 -06 -09 T092183042007 5.0 GAL BOTTLE RETURN -2.0 6.00 -12.00
Recd By:
08 -20 -09 44205387 ENERGY SURCHARGE 1.0 1.87 1.87
08 -20 -09 T092323042008 HINCKLEY 5.OG DRINK NON -SPILL 2.0 9.49 18.98
5.0 GAL BOTTLE RETURN -2.0 6.00 -12.00
5.0 GAL BOTTLE DEPOSIT 2.0 6.00 12.00
Recd By:
Total New Charges 21.85
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
p roducts, check your next delivery, a our bill and much more. Loci on Coda l
3035EP -0034
Previous Balance Payment Total New Charges G� Pay This Amount
$52.72 $52.72 $21.85 $21.85
Write the com acco number- on- yourcheck. remittanceand.matl mq h.payment in .the enclose d envelo =To. pay online _www.Hinckle 17
How to Read Your Statement a° mm Important Monthly Promotions:
u ❑,om"go�r. °,yoa,e, We Deliver! our
Reg ister online for access t0
l�u 1009 July xO uto9nda,, ?pp9 9onbd W.l.i'Filtr 9 Y
Delivery Calendar: M .w,a,,a,F, account. You can view and pay your bill,
check delivery schedule and 'order
Your scheduled deliveries for
the next three months. products all online.
Customer Account Number: Bottle Deposits
For prompt service, please use thisy
Highlights bottle deposits and returns.
number when referring to your account. X1
W U 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. Po,
Total New Charges:
This information provides totals for Mall Remittance With Payment To:
various products and transactions. Please detach remittance and mail
-V� 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 rep lacement 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 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.
a.`'19 Terms
5a(, p� 7 9 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
a I 5 4 7,4 I�
v
t. Y7
Total s
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
Clerk- 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
3 o fv7? 8S9 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
20
U r�
Cost distribution ledger classification if e
claim paid motor vehicle highway fund