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Home My WebLink About177721 09/29/2009 f CITY OF CARMEL, INDIANA VENDOR: 363386 Page 1 of 1 ONE CIVIC SQUARE BETH JACOBS CHECK AMOUNT: $74.17 CARMEL, INDIANA 46032 946 3RD AVE NW 'a•an `o CARMEL IN 46032 CHECK NUMBER: 177721 CHECK DATE: 9/29/2009 DEPA ACCOUNT PO NUMBER INVOICE NUMB A MOUNT DESCRIP 102 5023990 mm 74.17 OTHER EXPENSES 2040 936 1.101 SETH L. ,#ACOBS 784095887 946 3RD AVE. NW CAFlMEL. IN 46032 -1369 s u =,DATE c 9 fi r• a r� d g A PAY To HE ORDEROF DOLLARS .rl h S y 3 ti THE TRAVELERS CLEVELAND CL CLAIM 8 8 3 H 12618537 AUTO LIABILITY CLAIMS PO BOX 94918 CLEVELAND OH 44101 -9734 UCO2164 AM TRAVELEIRSJ DATE: 09/10/09 LOSS DATE: 06/08109 CARMEL FIRE DEPARTMENT FILE NUMBER: 031 AB UAB6701 A 2 CIVIC SQUARE REFERENCE 0002003565MM CARMEL IN 46032 CLAIMANT: BETH JACOBS ACCOUNT NAME: BETH JACOBS TRAVCO INSURANCE COMPANY EXPLANATION OF PAYMENT MEDICAL PAYMENTS 06/08/09 TO 06/08/09 $370.85 TOTAL PAID $370.85 Prov Inv 200901484 PAYMENT INQUIRIES? EMAIL AUTMRTPI@SPT.COM, FAX 877 --749 -0003, PH, 877 -838 -7281 253007806 DVRPUNS2- 1ziz9s DETACH CHECK DETACH CHECK Citibank, N.A. TRAVELERS 883H 12618537 6 3;2 D One Penns Way New Castle DE 79720 PD BOX 94918 THIS CHECK HAS A RED BACKGROUND CLEVELAND OH 44101 -9734 (216)643 -2474 DATE ACCOUNT NUMBER FILE NUMBER VOID IF NOT PRESENTED WITHIN 09/10/09 J98 031 AB UAB6701 A ONE YEAR AFTER DATE OF ISSUE THREE HUNDRED SEVENTY AND 85/100 PAY: M,7 U PAY CARMEL FIRE.DEPARTMENT TO THE 2 CIVIC SQUARE ORDER oF CARMEL IN 46032 U0021 V UC°2�sa AUTH IZED SIGNATURE ildmli i lii6liluuuulurinln l n6rli�lu lidu6rlirliri n6iln6didukuirr lri ln l nhr6ilrilul u ln6du1116 dI11uB16d1[ lullllul l l lullihddlidhhllullllll611ulllhilllllilrhlldlhdrd I mlurlilid6l [IIri6°IunIhllldddilLrilr II° L 26 L853711° l:031 L❑❑ 2 091: 3 I75830Eii° Date: 09!16/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 45032- (317 )571 -2605 Federal ID# 356000972 Bill To: JONATHON JACOBS ICD -9: 78652 E8130 946 3RD AVENUE NW CARMEL, IN 46032 From: 116TH ST &AAA WAY To: ST. VINCENTS HOSPITAL 1 HUMANA CLAIMS OFFICE Patient: BETH L JACOBS 00408668102 946 3RD AVENUE NW Insurance CARMEL, IN 46032- 2 Patient No: 200901484 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $370.85 $741.70 370.85 CPT Date Description Charges Credits 06/08/2009 3ASIC LIFE SUPP- EMERGENCY A0429 $325.00 06/06/2009 MILEAGE A0425 $45.85 08/21/2009 COMMERCIAL INSURANCE PAYMENT $296.68 09/04/2009 PAYMENT $74.17 09/15/2009 COMMERCIAL INSURANCE PAYMENT $370.85 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 09/16/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 Bill To: JONATHON JACOBS ICD -9: 78652 E8130 946 3RD AVENUE NW CARMEL, IN 46032 From: 116TH ST &AAA WAY To: ST. VINCENTS HOSPITAL HUMANA CLAIMS OFFICE Patient: BETH L JACOBS 00408668102 946 3RD AVENUE NW Insurance CARMEL, IN 46032- 2 Patient No: 200901484 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $370.85 $667.53 296.68 CPT Date Description Charges Credits 06/08/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 66/08/2009 MILEAGE A0425 $45.85 08/21/2009 COMMERCIAL INSURANCE PAYMENT $296.68 09/04/2009 PAYMENT $74.17 09/15/2009 COMMERCIAL INSURANCE PAYMENT $370.85 09/16/2009 REFUND -74 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER 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. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) er m b U ,s ,7 etP Gr.c �7 E q --J Total 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 1 V D ON ACCOUNT OF APPROPRIATION FOR G 1 ,�rnhulaK�e (�-hl n ho ro 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 SEP 2 9 2009 2 i Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund