179284 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: 363565 Page 1 of 1
ONE CIVIC SQUARE DARLENE KLIMEK
CARMEL, INDIANA 46032 4602 WHITNEY ROAD CHECK AMOUNT: $266.00
NOBLESVILLE IN 46062
CHECK NUMBER: 179284
CHECK DATE: 11/11/2009
DE PARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 266.00 REFUND
i
CLAIM NO. 14 -2337 -161 POLICY NO 1421- 059 -14 LOSS DATE 05 -17 -2009 PAYMENT NO 1 18 560241 J
Cover.a a DekH Yi :on Amount COL Pay Cd DATE 10 -15 -2009
MEDICAL PAYMENT $331.55 600 2 AMOUNT $331.55
�ryyy TIN 14- 356000972
0 'ED G 2 0 20
REMARKS 5/17/2009
STATE FARM MUTUACA UTOMOBILE INSURANCE COMPANY!- a'
1 18 560241 J
WEST LAfAYETTE IN JPMORGAN::CH'ASE BANK ,NA "56=1544/441,'
MPC;dsND:IANA .t$ 501 'L -025; OH
o COL
10 15 2009
il cc IM No 14r2337-16:1 INSURED SARAVA SRINIVA DATE M M Da Y Y Y
LOSS DATE'.05 -17- 2009'. S ON 9fHALF- "'b RLENE,. KLIMEK
ACTLY THREE HUNDRED THIRTY -ONE AND 55 /100 DOLLARS *331 55;
Pay to the
Order of CARMEL FIRE DEPARTMENT
2 CIVIC SQ
CARMEL IN 46032 -2584
w e
m�
r
TH IZED:SIGNA:TURE
!i L8b75602L,Ln- 1:0441L54431:62629023Do
i
5: owl
F �ta w'+3
f{ 5 V S i
DARLENEM,KLIMEIC
s .2�11t112
x r s t 4r nz�aT O Dsl�9
4
s
w
W
uP
Wit-
WILDLIFE PORTRARSB
H.6— CIeMe
Date: 10/28/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
J
Bill To: SRINIVASAR SARAVANAN ICD -9: 7231 7245 7295 E8130
4602 WHITNEY ROAD
NOBLESVILLE, IN 46062
From: 116TH ST &MERIDIAN ST
To: CLARIAN HOSPITAL NORTH
1 ANTHEM BC /BS/ 37010
Patient: DARLENE KLIMEK ADDAN1829347
4602 WHITNEY ROAD Insurance
NOBLESVILLE, IN 46062- 2 STATE FARM INSURANCE /2362
CLM #14- 2337 161
Patient No: 200901283
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$331.55 $331.55 $0.00
CPT
Date Description Charges Credits
05/17/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
05/17/2009 MILEAGE A0425 $6.55
10/06/2009 PAYMENT $266.00,
10/20/2009 COMMERCIAL INSURANCE PAYMENT $331.55
10/28/2009 REFUND 266.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 10/28/2009
CARMEL FIRE DEPARTMENT J
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
Bin To: SRINIVASAR SARAVANAN ICD -9: 7231 7245 7295 E8130
4602 WHITNEY ROAD
NOBLESVILLE, IN 46062
From: 116TH ST &MERIDIAN ST
To: CLARIAN HOSPITAL NORTH
ANTHEM BC /BS/ 37010
Patient: DARLENE KLIMEK ADDAN1829347
4602 WHITNEY ROAD Insurance
NOBLESVILLE, IN 46062- 2 STATE FARM INSURANCE /2362
Patient No: 200901283 CLM #14- 2337 -161
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$331.55 $597.55 266.00
CPT
Date Description Charges Credits
05/17/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
05/17/2009 MILEAGE A0425 $6.55
10/06/2009 PAYMENT $266.00
10/20/2009 COMMERCIAL INSURANCE PAYMENT $331.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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
�ar I n e /5 1 l'1) e- K Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
n 6(Lr r t -c Pr C
Total�(�. (9�
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
1.�A, e
%Vo d/e s V
ON ACCOUNT OF APPROPRIATION FOR
g &0
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I 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
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund