180903 12/30/2009 (2) CITY OF CARMEL, INDIANA VENDOR: 356305 Page 1 of 1
0 ONE CIVIC SQUARE DARRELL D NORRIS
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CARMEL, INDIANA 46032 101 2ND AVE SW, #2C CHECK AMOUNT: $14.30
CARMEL IN 46032 CHECK NUMBER: 180903
CHECK DATE: 12/30/2009
D EPARTMENT ACCOUNT PO NUMBER INVOICE NUMBE AMOUNT DESCRIPTION
1160 4343004 14.30 TRAVEL PER DIEMS
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PRESCRIBED BY STATE BOARD OF ACCOUNTS r.
GENERAL FORM NO. 101 (1986)
MILEAGE, CLAIM
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Ir ��FIVE
(GOVERNMENTAL UNIT)
e ON ACCOUNT OF APPROPRIATION NO. FOR'
(OFFICE,, BOARD, DEPARTMENT OR INSTITU ON) b
ER
ATE FROM TO SPEEDOMET RERDING AUTO MILErA�GE MILES
I POINT POINT START FINISH NATURE OF BUSINESS TRAVELED
ER MILE
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AUTO LICENSE NO. TOTALS
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map. v
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount claimed is leg h y due, after allowing SlI t credits
and that no part f the sa a has been paid. f/'
Date 1,2 7/,
i
Claim No. Warrant No. I have examined the within claim and hereby
IN FAVOR OF certify as follows:
A That it is in proper form.
That it is duly authenticated as required
by law
That it is based upon statutory authority
r That it is apparently correct
incorrect
Disbursing Officer
On Account of Appropriation No. for
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