174549 07/08/2009 CITY OF CARMEL, INDIANA VENDOR: 363030 Page 1 of 1
ONE CIVIC SQUARE MARK E WILES CHECK AMOUNT: $61.00
CARMEL, INDIANA 46032 11800 FOREST LANE
CARMEL IN 46033 CHECK NUMBER: 174549
CHECK DATE: 7/812009
DEPART ACCOUNT PO NUMBER INV OICE NUMBER AMOUNT D ESCRIP TION
101 5023990 61.00 REFUND
T.
OF Cqq COMPLETE &t RETURN
REFUND REQUEST
THIS FORM TO:
Building Code Services City of Carmel
Ph. (317) 571 -2444 Fax (317) 571 -2499 Building &r Code Services
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enm
One Civic Square;
Carmel, IN 46032
Q
PERMIT #(s): gO
Lot Subdivision, or Address of Construction:
l d'oo fvl- 44 f KJ I X6 a,�-
(If more than one address needs to be listed and will not fit, please attach a printed list of all permits, with
their corresponding permit
Please print-6r type the reason for the requested refund, and specific fee or fees
which are requested, in the lines below:
(�l Od 7 J t b
U� ✓(/N 112
TO REFUND OUNT REQUESTED:
T7 lO
Applicant Signature Date
tj l L e P
Applicant Name Printed Company Name (If applicable)
APPLIICANT ADDRESS:
f
C1 0o 4iZCT T 47,
Street Address
City ST Zip
Phone Fax
FOR OFFICE USE ONLY
Total amount for fees that ARE available for refund:
Fees that are NOT available for refund:
Refund approved by: Date:
Date submitted for Payment: Amount Approved:
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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
Purchase Order No.
6 Terms
N g-'49a, Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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
1 14 A
IN SUM OF
4o3
ON ACCOUNT OF APPROPRIATION FOR
Jc s
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
20 d
ignature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund