167788 01/20/2009 CITY OF CARMEL, INDIANA VENDOR: T362363 Page 1 of 1
ONE CIVIC SQUARE DAVID MARTIN
/ro CARMEL, INDIANA 46032 13106 HAZELWOOD DR CHECK AMOUNT: $218.95
CARMEL IN 46033 CHECK NUMBER: 167788
CHECK DATE: 1/20/2009
DEP ARTMENT ACCOUNT PO NUMBER INVO NU MBER AMOUN DESCRIPTION
1047 4358400 215731 218.95 REFUNDS AWARDS INDE
PASS REFUND RECEIPT
Receipt 215731
Payment Date: 01/06/2009
Household 2718
Home Phone: (317)844 -2525 JAN 1 2 2009
Work Phone:
DAVID MARTIN Monon Center
13106 HAZELWOOD DR. Carmel IN 46032
CARMEL IN 46033
Phone: (317)848 -7275
Fed Tax ID #35- 6000972
Pass Details
CANCELLATION Refund Of 218.95
Pass Holder: Judith Martin Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Yly FT Alt Res (YFTAR), #48807 21.05 0.00 21.05 0.00 0.00
Valid Dates: 12/05/2008 to 12/05/2009 Pass Cancellation)
Fee Details: Fee Description Amount Count Discount Sales Tax Total Fee
Yearly Fitness Adult 21.05 1.00 0.00 0.00 21.05
Cancel Reason: not using
GIL Code Description Account Number Cst Cntr Description Account Number Amount
999999 Control Account (AP) Enter Control Acct CNTRL Contro! Account (AP) Enter Control Acct here 218.95 DR
The REVENUE account was DEBITED and the CONTROL account was CREDITED on the day of the refund.
Finance will have to DEBIT the CONTROL account for the amounts listed above after the checks have been written to the customers.
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 01106109 17:49:18 by RDG FEES CHANGED ON CANCELLED ITEMS 218.95
DISCOUNT APPLIED AGAINST CANCELLED FEES O 0.00
SALES TAX CHARGED ON CANCELLED FEES 0.00
NET FROM CANCELLED ITEMS 218.95
TOTAL AMOUNTF REFUNDED 218.95
NEW NET HOUSEHOLD BALANCE r f �7 0.00
Refund of 218.95 Made By REFUND FINAN With Reference
Alf refunds are subject to State Board of Accounts claim procedure and may take 4 -6 weeks to process. check wi I be
issued. No cash or credit card refunds.
Authorized Signature Date Authorized Signature Date
Ll
Page 1
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
Martin, David Terms
13106 Hazelwood Drive Date Due
Carmel, IN 46033
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
116109 215731 Refund 218.95
Total 218.95
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
1 20
Clerk- Treasurer
Voucher No. Warrant No.
Martin, David Allowed 20
13106 Hazelwood Drive
Carmel, IN 46033
In Sum of
218.95
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1047 215731 4358400 218.95 1 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
15 -Jan 2009
Signature
218.95 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund