HomeMy WebLinkAbout177297 09/15/2009 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER
CHECK AMOUNT: $55.00
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE
off �o CARMEL IN 46032 CHECK NUMBER: 177297
CHECK DATE: 9115/2009
DEPARTM ACCOU PO NUMBER INVOICE NUMB AMOUNT DE
1207 4343004 REIM 55.00 TRAVEL PER DIEMS
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Prescribed by State Board of Accounts
General Form No. 101
MILEAGE CLAIM
TO DR.
(Governmental Unit)
�.2Q f On Account of Appropriation No. for
(Office, Board, Department or Institution)
DATE FROM TO ODOMETER READING" NATURE OF BUSINESS AUTO MILES MILEAGE
20 Point Point Start Finish TRAVELED PER MILE
9
f 67' `7�' 3 u
0 k"e Gf� f t� S ry� /F/ ��C/
113 16 9 o %7' m/.c/�sc'� a /at `7s ?y I 't 41 6
�'Z.; /s 75_9A s7.V
"1 0 �*1a.5 2 /s ?J9s SIs 9 9 L` t '2 ao
G M1 a4 I r6n /f .s Axr_cT 566– 15. /s Zv ;GO s.-) t-
C0 "'e-se /4 7423 /s 7.4 �f
X� J /Q 4 rJ 0/-1 &-*crams i fit/ /S' 91 aZ 77 041
Q -J o L l a a o
p J S a 7 -4 a
0 ecx t/�' 115" c A S'
0 o we d '2 a4
3 D o 2 �O
09 �2 D S osi Q o
.7 U
09 u �s7�'9s /erg. 9 ,1. 2
b
D 6 9 �o u,t cE 14-7 9 3.x" S.7 7 /7 /c! 5 i 7 2 ,c) r� a `s 5
N X7939 is ,/.2
&l 0 7) rr 11 r.�.rj�' 9G F
Auto License No. TOTALS$ CJD
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 I Ily due, after
allowing all just credits, and that no part of the same has been paid.
Date
Clcdm No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon statutory autho:
That it is apparently correct
incorrect
On Account of Appropriation No. for
J /;�D—/ Disbursing Officer
3 °O o 0
Allowed 20
in the sum of o
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I 0
(Board or Comission)
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