177071 09/15/2009 CITY OF CARMEL, INDIANA VENDOR: 360618 Page 1 of 1
ONE CIVIC SQUARE STEPHANIE MARSHALL CHECK AMOUNT: $566.72
CARMEL, INDIANA 46032 578 TULIP POPPLUR CREST
CARMEL IN 46033 CHECK NUMBER: 177071
CHECK DATE: 9/1512009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER V AMOUNT DESCRIPT
902 4347500 566.72 GENERAL INSURANCE
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Richard Marshall, Jr. SVP Worldwide COBRA Coupon #3 July /2009
Coverage Tier Period Premium
BCBS HDHP/HSA Medical Plan Employee Family 07/01/2009 07/31/2009 310.68
Delta Dental Plan Employee Family 07/0112009 07/31/2009 22.71
Comments Notes: Subtotal: $333.39
Amount Paid: $0.00
Return this Coupon and Your Payment to: Coverage for: Total Due: $333.39
Medcom Richard Marshall, Jr. Due Date: 07/0112009
P.O. Box 10269 Total Enclosed:
Jacksonville, FL 32247 -0269 578 Tulip Poplar Crest
Carmel, IN 46033 Make Check Payable to:
Medcom
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P.O. Box 534 141811 "FI6A Bank, 645 N Btir Si eet, Suite 320, Sheboygan VIA 53C)bt
Sheboygan, W1 53082 -0?t39 a mail sohs&bankct�m
Para un representante en X4506 W.tavcr Ilam r al E3cfr35 631
Richard C Marshall Jr r.k k h
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578 TuIiP ;Poplar Crest
Carmel, ON 461133 ra 2am�
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BALANICE LAST STATENIENT 0513012009 5,351.67
DISTRIBUTIONIVIATHURAVVAL CHECK #100 333,39 0710312009 5
DISTRIBUTIGN(WtTHDRAWAL 157.$8 0711 2009 4.830.30
RATE CHANGE OLD NEIN 1.2d °,i: :1.7,'06,20UP, ?,?3£._?S
DISTRIBUTIt?N111NI71-ORAWVAL GHECk# 1132 10,74 +07fO912009 5
INTER EST PAID 5.49 0713112009 4.325.05
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Richard Marshall, Jr. SVP Worldwide COBRA Coupon 94 AugusV2009
Coverage Tier Period Premium
BCBS HDHPIHSA Medical Plan Employee Family 08/01/2009 08/31/2009 310.68
Delta Dental Plan Employee Family 08/0112009 0813112:009 22.71
Gpmments I Notes: Subtotal: $33139
Amount Paid: $0.00
Return this Coupon and Your Payment to: Coverage for. Total Due: $333.39
Medcom Richard Marshall, Jr. Due Date: 08/01/2009
P.Q. Box 10269 Total Enclosed:
Jacksonville, FL 32247 0269 578 Tulip Poplar Crest
Carmel, IN 46033 Make Check Payable to:.
rr edwm
ToIE Free Aulom3tedBankline i80pr 555 3512
5 f i_Ne Pesnnai B�iikel (8UD }357 6246 7atnlJPm'CST M F i 6
Fax (8 7) 851 -70 41
A Division of Wt -hster Bank,N.A. Int mei`8anlang vnvw� hsehankeam
P.O. Box 934 Mad NSA Bank SOS N,,E3th Street Sutte 320 ShelwYSan, WI 53081
SLeboygan, WI 5308 2-0939 a marl aS6afs�hs3bankcor�s
Para un representarsteen espsfVo' poriavor iiemt al 366 357 6232
Richard C Marshall Jr 70 s
578 Tttiip Poplar Crest Y
Carmel, IN 46033
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HSA ACCOUNT
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BALANCE LAST STATEMENT 0713112009 4,525.05
DiST:RIBUTIGNiWIT:HDRAWAL CHECK 4103 333.39 081 1212009 9,401.66
INTEREST PAID 487 08/3112009 4,456.53
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Prescribed by State Board of Accounts 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
���h� i' /y�rs�,•�� Purchase Order No.
6- �lJl��v �ap�9� Cr�s� Terms
C Date Due
Invoice Invoice Description Amount
Date Number (or note attac invoice(s) or bill
CY S/O �O 3— 3 6
Total 56'6 72
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
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
9�2 �3��soo
Board Members
Po# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoices or
}a ;3 S6G=72 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
200
Signature
Director Of Opprations
Cost distribution ledger classification if It e
claim paid motor vehicle highway fund