173661 06/18/2009 CITY OF CARMEL, INDIANA VENDOR: T357819 Page 1 of 1
ONE CIVIC SQUARE SANDRA JOHNSON CHECK AMOUNT: $143.00
CARMEL, INDIANA 46032 329 STONEHEDGE DR
CARMEL IN 46032 CHECK NUMBER: 173661
CHECK DATE: 6/18/2009
DEP ACCOUNT PO NUMBE INVOICE NUMBER AMOUNT DESCRIP
1701 4343004 143.00 TRAVEL PER DIEMS
I
Prescribed by State Board of Accounts General Form No. 101 1955
MILEAGE CLAIM
l O TO S ��c�(2 �J t�h Y DR.
(Governmental Unit)
C l,-"" Y On Account of Appropriation No. for
(Uffice, Board, Department or Institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE V
20Q Point Point Start Finish TRAVELED PER MILE
Z k— c 10 tv k O—+i I a b I '7r 5 fl
"7 Lam' CA-- (.q Zyo d M i 1 30 O
Auto License No. TOTALS (f
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, afte
allowing all just credits, nd that no part of the same has been paid.
i
Date f0
t
Claim No, J Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as required
by law;
That it is based upon statutory authority;
H3 That it is apparently correc incorrect
On Account of Appropriation No. l for
4�30 04 (7� /1 Disbursing Officer
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