177721 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•
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PAY To HE
ORDEROF
DOLLARS .rl
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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
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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