HomeMy WebLinkAbout173538 06/10/2009 `i i c�yYi CITY OF CARMEL, INDIANA VENDOR: 362954 Page 1 of 1
ONE CIVIC SQUARE ANDREW SHIRLEY
CARMEL, INDIANA 46032 5733 CHENSFORD DRIVE
INDIANAPOLIS IN 46226 CHECK AMOUNT: $22.55
CHECK NUMBER: 17353$
CHECK DATE: 6/1012009
DEPARTME ACCOU PO NU INVOICE NUMBER AMOUNT DESCRIP
1207 4343004 22.55 MILEAGE
a
Prescribed by State Board of Accounts General Form No. 101 (1955)
C MILEAGE CLAIM
✓�I ir1 To DR.
(Governmental Unit) s
C �'O 4 C.l �g 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
s-z ce J 7 2, 15Z 6 a
ao Z 2.700
r tilQ,r �U 5
1'h h r v� l 7 t S
LEE
Auto License No. 7 f ZO Z 5s TOTALS
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 7c- 1
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FA R OF
That it is in proper form;
That it is duly authenticated as required
by law;
That it is based upon statutory authority;
That it is apparently correct
incorrect
On Account of Appropriation No. for
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