179779 11/24/2009 CITY OF CARMEL, INDIANA VENDOR: 363352 Page 1 of 1
ONE CIVIC SQUARE WES NICLEY
CARMEL, INDIANA 46032 4544 W 200 N CHECK AMOUNT: $2,500.00
LEBANON IN 46052 CHECK NUMBER: 179779
CHECK DATE: 11/24/2009
DEPAR TMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
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301 5023990 2,500.00 OTHER EXPENSES
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C ITY OF CARMEL
ADOPTION AssISTANCE CLAIM FORM
SEE REVERSE SIDE FOR INFORMATION AND INSTRUCTIONS
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Employee Name (First Ml Last): Vl ENS, N`
Department: fQ,
Social Security Number. oa -I yeK4 Work Phone: 31-) 5 1
Employee ID Number. Home Phone IUCS) On'6 Oa <b 7
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Child's Name: (Yl Date of Birth: qVo, /0(:N
SSN (if known): tx1 Final Adoption Date: t 3 /0ok
Attach copy of adoption decree if adoption has been finalized.
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Date: Paid To: Services Rendered: Amount:
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Attach original itemized receipts in U.S. dollars for all expenses listed above. No reimbursement will be made without appropriate documentation.
Attach separate sheet of paper for additional expenses.
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7hereby ue st reimbursement for the adoption expenses listed above. By signing below, I certify that
Check appropriate box: The child identified above has been placed in my home pursuan o adoption 0'; or
The adoption of the child identified above has been finalized and
To the best of my knowledge, each expense listed above is a qualified adoption expense under the City of Carmel
Adoption Assistance Program; and
All statements and documentation relating to this claim are true and complete.
1 understand that incomplete or inaccurate information may adversely affect my eligibility for benefits through the
Adoption Assistance Program.
Employee ignature: Date:
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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.
Payee
Wes Wayne Nicley Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
11/13/09 Adoption Assitance
Total $2,500.00
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 1\10F 1123/99 WARRANT NO.
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ALLOWED 20
Wes Wayne Nicley IN SUM OF
260 2nd Street SW
Carmel, IN 46032
$2,500.00
ON ACCOUNT OF APPROPRIATION FOR
Medical Escrow
301 Medical Escrow Account
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
301 0 301 $2,500.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund