173416 06/10/2009 CITY OF CARMEL, INDIANA VENDOR: 362930 Page 1 of 1
ONE CIVIC SQUARE XIAOMEI LAN
0 CARMEL, INDIANA 46032 CHECK AMOUNT: $119.07
169 LOTUS DRIVE APT 7
o za CARMEL IN 46032 CHECK NUMBER: 173416
CHECK DATE: 6/10/2009
DEPARTMENT ACCOUNT PO NUMBER INV NUM BER A MOUNT DESCRIPTION
1047 4358400 119.07 REFUNDS AWARDS INDE
i e y
PASS REFUND RECEIPT
Receipt 266847
Payment Date: 06/01/2009
Household 27243
Horne Phone: (407)484 -3632
Work Phone:
XIAOMEI LAN Monon Center
169 LOTUS DRIVE APT 7 Carmel IN 46032
CARMEL IN 46032
Phone: (317)848 -7275
Fed Tax iD #35- 6000972
Pass Details
CANCELLATION Refund Of 77.85
Pass Holder: Xiaomei Lan Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Seas AQ Adt Res (SAQAR), #69603 7.15 0.00 7.15 0.00 0.00
Valid Dates: 05/2312009 to 09/07/2009 Pass Cancellation)
Fee Details: Fee Description Amount Count Di scount Sales Tot al Fee._
Seas Aquatics Ad Res 7.15 1.00 0.00 0.00 7.15
Re� a My son can not swim with provided vest, would like to switch to 10 visit pass
CANCELLATION Refund Of 41.22
Pass Holder: Raymond Lan Fees Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: Seas AQ Yth Res (SAQYR), #69604 3.78 0.00 3.78 0.00 0.00
Valid Dates; 05/2312009 to 09/07/2009 Pass Cancellation)
Fee Details; Fee_geacriPtign Amount CQunl, Discount _Sales Tax Total Fe e_
Seas Aqua Yth Res 3.78 1.00 0.00 0.00 3.78
Cancel Reason: My son can not swim with provided vest, would like to switch to 10 visit pass
GIL Cade, fescri Account Nun7ber Csl_Cntr Descri ption Ac count N umber,, Amopnt
999999 Control Account (AP) Enter Control Acct CNTRL Control Account (AP) Enter Control Accl here 119.07 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 06/01/09 06:02:34 by RDG FEES CHANGED ON CANCELLED ITEMS 119.07
DISCOUNT APPLIED AGAINST CANCELLED FEES 0.00
SALES TAX CHARGED ON CANCELLED FEES 0.00
NET:AM6UNT FROM CANCELLED ITEMS
TOTAL AMOUNT, REFUNDED:, 119:07
Page 1
PASS REFUND RECEIPT
Receipt 266847
Payment Date: 06!0112009
Household 27243
NEW NET HOUSEHOLD BALANCE 0.00
Refund of 119.07 ade By REFUND FINAN With Reference
All refunds sect to State Board of Accounts claim procedure and may take 4 -6 weeks to procesoECA check w' I be
issued. No cash or credit card refunds.
prized Signature Date authorized Signature Date
Page 2
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.
Lan, Xiaomei Terms
169 Lotus Drive, Apt. 7 Date Due
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
611109 266847 Refund 119.07
Total 119.07
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.
Lan, Xiaomei Allowed 20
169 Lotus Drive, Apt. 7
Carmel, IN 46032
In Sum of
1 19.07
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT#rFITLE AMOUNT Board Members
Dept
1047 266847 4358400 119.07 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
4 -Jun 2009
4 7/rI7.
Signature
119.07 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund