176817 09/02/2009 CITY OF CARMEL, INDIANA VENDOR: 362631 Page 1 of 1
ONE CIVIC SQUARE DENISSE JENSEN
CARMEL, INDIANA 46032 5298 BREAKERS WAY CHECK AMOUNT: $69.60
CARMEL IN 46033 CHECK NUMBER: 176817
CHECK DATE: 9/2/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1047 4358400 69.60 REFUNDS AWARDS INDE
PASS REFUND RECEIPT
Receipt 328988
Payment Date: 08/17/2009 y�
Household 10131
Home Phone: (317)816 1606 AUU 2009
Work Phone: (317)435 -2571
DENISSE JENSEN Carmel Clay Parks Recreation
5298 BREAKERS WAY 1235 Central Park Drive East
CARMEL IN 46033 Carmel IN 46032
Phone: (317)848 -7275
Fed Tax ID #356000972
Pass Details
CANCELLATION Refund Of 69.60
Pass Holder: Denisse Jensen Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp Pass HH (CORPHH), #71359 139.20 0.00 0.00 13920 0.00
Valid Dates: 06/11/2009 to 06/11/2010 Pass Cancellation)
Fee Details: Fee De Amount Count Discount Sales Tax Total Fee
Corporate Household 139.20 1.00 0.00 0.00 139.20
CANCELLATION
Pass Holder: John Jensen Fees Tax Discount Prev Paid Cur Paid Amount. Due
Pass Type: Corp Pass HH Ad (CORPHADD), #71360 0.00 0.00 0.00 0.00 0.00
Valid Dates: 06/11/2009 to 06/11/2010 Pass Cancellation)
CANCELLATION
Pass Holder: Alex Jensen Fees TQX Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp Pass HH Ad (CORPHADD), #71362 0.00 o.DO 0.00 0.00 O.00
Valid Dates: 06/11/2009 to 06/11/2010 Pass Cancellation)
CANCELLATION
Pass Holder: Isabel Jensen Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp Pass HH Ad (CORPHADD), #71361 0.00 0.00 0.00 0.00 0.00
Valid Dates: 06/11/2009 to 06/11/2010 Pass Cancellation)
417
Page 9 1
PASS REFUND RECEIPT
Receipt 328988
Payment Date: 08/17/2009
Household 10131
CANCELLATION
Pass Holder: Mihail Dimitrov Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Corp Pass HH Ad (CORPHADD), #71363 0.00 0.00 0.00 0.00 0.00
Valid Dates: 06/11/2009 to 06/11/2010 Pass Cancellation)
GIL Code Description Account Number Cst Cntr Description Account Number Amou nt
999999 Control Account (AP) Enter Control Acct CNTRL Control Account (AP) Enter Control Acct here 69.60 DR
The REVENUE account was DEBITED and the CONTROL account was CREDITED on the day of the refund.
Finance will have to DEBIT the CONTROL account for the amounts listed above after the checks have been written to the customers.
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 08/17/09 13:39:30 by ABK FEES CHANGED ON CANCELLED ITEMS 208.80
DISCOUNT APPLIED AGAINST CANCELLED FEES 0-00
SALES TAX CHARGED ON CANCELLED FEES 0.00
SURCHARGE APPLIED AGAINST CANCELLED FEES 139.20
NET AMOUNT FROM CANCELLED ITEMS 69.60
TOTAL AMOUNT REFUNDED 69.60
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 69.60 Made By REFUND FINAN With Reference No longer eligible
All refunds are subject to State Board of Accounts claim procedure and may take 4 -6 weeks to process. A check will be
issued. No cash or credit card refunds.
1
P
Authorized Stature Date Authorized Signature Date
Page ff 2
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
Jensen, Denisse Terms
5298 Breakers Way Date Due
Carmel, IN 46033
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
8/17/09 328988 Refund 69.60
Total 69.60
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.
Jensen, Denisse Allowed 20
5298 Breakers Way
Carmel, IN 46033
In Sum of
69.60
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITL AMOUNT Board Members
Dept
1047 328988 4358400 69.60 1 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
27 -Aug 2009
Signature
69.60 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund