Loading...
180482 12/16/2009 CITY OF CARMEL, INDIANA VENDOR: 360618 Page 1 of 1 ONE CIVIC SQUARE STEPHANIE MARSHALL CHECK AMOUNT: $283.55 CARMEL, INDIANA 46032 578 TULIP POPPLUR CREST CARMEL IN 46033 CHECK NUMBER: 180482 CHECK DATE: 12/16/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4347500 283.55 GENERAL INSURANCE Richard. Marshall, Jr. SVP Worldwide COBRA Coupon #3 November /20019 Coverage Tier Period Premium BOBS ee+ la H ©HP /HSA Medical Plan Employee y Farnil 1i10 1 /2001 17130/2009 310.68 Delia Dental Plan Employee Family 11!0112009 11430/2009 22.71 f j s 1 I Comments Notes: Subtotal• 533339 Amount Paid; $000 Total Due: $333,39 Return this Coupon and Your Payment to: Coverage for: Medcom Richard Marshall, Jr. Due Date: 11/0112009 f P.O. Box 10269 Total Enclosed: S� Jacksonville, FL 32247 -0269 578 Tulip Poplar Crest Carmel, IN 46033 Make Check Payable to: Medcorn i RICHARD C MARS JR 1 0 578 TULIP POPLAR CREST 79- 794/759 CARMEL, IN 46033 j 2 Pay to the Order For �lijzible Medical Expenses Only l ;Rrwcribkby State Hoard otAccounts 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 Jim /��s �y�� Purchase Order No. i 7� Sb' T�ir`,;,o �0�/ C ps Terms 164 .J' Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 2. 3 p fi k Total �3 S I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in a6' rdance with IC 5- 11- 10 -1.6. e f 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF 5 7g %y/i, ON ACCOUNT OF APPROPRIATION FOR Board Members Po# or INVOICE NO. ACCT# /TITLE AMOUNT DEPT. k 1 hereby certify that the attached invoice(s), or 9oz /��09 y�_5 s ��Sc� 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 2 /G 20 0;� Si lature Cost distribution ledger classification if itle claim paid motor vehicle highway fund