206762 02/28/2012 CITY OF CARMEL, INDIANA VENDOR: 366055 Page 1 of 1
ONE CIVIC SQUARE MICHAEL NANAJI
CARMEL, INDIANA 46032 12503 BROOKLINE ST CHECK AMOUNT: $390.10
CARMEL IN 46032
CHECK NUMBER: 206762
CHECK DATE: 2/2812012
DEPARTMENT ACCOUNT PO NUMBER INV OICE NUMBER AMOUNT DESCRIPTION
102 5023990 390.10 AMBUL REFUND
Date: 02/15/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 Federalm# 356000972
ACCOUNT HISTORY
BRI To, MICHAEL NANAJI ICD -9: 7840 E8130
12503 BROOKLINE
CARMEL, IN 46032
From: 103RD &MERIDIAN
To: IU HEALTH NORTH
1 ANTHEM BLUE CROSS BLUE
Patient; MICHAEL NANAJI MYY810820421
12503 BROOKLINE Insurance
CARMEL, IN 46032- 2
Patient No: 201102936
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
$390.10 $390.10 $0.00
CPT
{c� =i."" ry�f. ym e' INS
1a gall I].es.crl tlOn Id s�
1 rrv ,.y CI
§'Iti;�C�il ��e. '�hil 11 .n"�.la 4 6 y, 0 Z.ay�ya`. 5�J"&��Ih
10/27/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
10/27/2011 MILEAGE A0425 $15.10
12/28/2011 PAYMENT $390.10
02/10/2012 COMMERCIAL INSURANCE PAYMENT $390.10
02/15/2012 REFUND 380.10
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 02/15/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317 )571 -2605 Federal !D# 356000972
ACCOUNT HISTORY
Bill To: MICHAEL NANAJI ICD -9: 7840 E8130
12503 BROOKLINE
CARMEL, IN 46032
From: 103RD &MERIDIAN
To: IU HEALTH NORTH
1 ANTHEM BLUE CROSS BLUE
Patient: MICHAEL NANAJI MYY810820421
12503 BROOKLINE Insurance
CARMEL, IN 46032 2
Patient No: 201102936
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
$390.10 $780.20 390.10
CPT
ii 's.,.# a P. �`�9 tW a e, a ar.
iP r� f1i1J!"'1. `4 4 .�v� ,�..A....ikNZ...aL. 'fr". ,,,,,'rr "'r ,,w
�.,;i rr t pa ri.� L E u t .Ini. r n
di i h v A w T IeJ C N', t3`� t o
r Descrlption �,�1ea ,ai;.r fi Char es
U�,,. -11, a rfi a r a IS r, rr i Q
,r: �n F w., ii�.:�n m v, n u �i�� &P u� fr a �ye.*A ei� es >vl4L �N f: hF w� atareu�a r...�,o
10/27/2011 BASIC LIFE SUPP— EMERGENCY A0429 $375.00
10/27/2011 MILEAGE A0425 $15.10
12/28/2011 PAYMENT $390.10
02/10/2012 COMMERCIAL INSURANCE PAYMENT $390.10
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.
j l Payee
I C 1 QP./ �O-A 12 I Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
S
Total ,3
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.
I_ ALLOWED 20
��Q/?U i i IN SUM OF 39Q
,_1q X63 �rd 0 ,01 fie .57
t r�crIn 1, Z Ldl� 03
990 /O
ON ACCOUNT OF APPROPRIATION FOR
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
FEB 2 4 2012
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund