172919 05/27/2009 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
0 ONE CIVIC SQUARE PAMELA LISTER
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $55.00
CARMEL IN 46032
a CHECK NUMBER: 172919
CHECK DATE: 5127/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUM A DESCRIPTION
1207 4343004 55.00 TRAVEL PER DIEMS
Prescribed by State Board of Accounts General Form No. 101 (1955)
MILEAGE CLAIM
p p (N\ S 7'(`�° TO �'i C� �Qcr�r� DR.
Unit)
(Governmental
1 7 ,UeCY�L'i/�i /j On Account of Appropriation No. for
(Office, BCzfrd, Department or Institution)
DATE FROM TO ODOMETER READING' NATURE OF BUSINESS AUTO MILES MILEAGE 55
206 Point Point Start Finish TRAVELED PER MILE
o` �au <5 c U Sd 1 a aG
kL 41 S
k,4_ a 6
s U
Me
Go ccrLL /1
o /S'(e //pS ti oz d
i /1WJ :[�?+✓li /6S' S' Cc -e- old
r Z
5 6
S owls C<
SS Gl 4 (a G /,5:7& 2 c t .2
S Co I cr-e—SE fiCJ J /�T as 7 i
5
5" ,�g3 S(o 47 2d
_S?" 57 a G
35
fly i/ a 3zJ 1 ao.
Auto License No. TOTALS S
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
Date
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
;nn j O That it is in proper form;
P I LA r�`�- That it is duly authenticated as required
by law;
That it is based upon statutory authority;
U v That it is apparently incorrect
On Account of Ap o 4 ao priation No. for
4 ro I� I Disbursing Officer
l (Q '0 B c
C U CD
Allowed 20 0 n o
in the sum of
0 5
e
(D �1
5 VV
o x
m p
m
0 mM
(Board or Corrunission) :e
FILED cD
m �r
o m
o
m
0 m
ch o
cial Title)
0 Q 0
i�6y'�