HomeMy WebLinkAbout179851 11/24/2009 a CITY OF CARMEL, INDIANA VENDOR: 363604 Page 1 of 1
ONE CIVIC SQUARE IRENE SOBOTKA
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CARMEL, INDIANA 46032 4650 W 121ST ST N CHECK AMOUNT: $370.85
ZIONSVILLE IN 46077 CHECK NUMBER: 179851
CHECK DATE: 11/24/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
'102 5023990 370.85 OTHER EXPENSES
Date: 11/18/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federai ID# 356000972
3 jA x°
Bill To: IRENE SOBOTKA ICD -9: 9596 E8888
4650 W 121 ST ST
ZIONSVILLE, IN 46077
From: 12999 N PENNSYLVANIA APTISUITE# 106
To: ST. VINCENTS HOSPITAL
1
Patient: IRENE SOBOTKA
4650 W 121 ST ST Insurance
ZIONSVILLE, IN 46077 2
Patient No: 200902208
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$370.85 $370.85 $0.00
CPT
Date Description Charges Credits
08/29/2009 BASIC LIFE SUPP— EMERGENCY A0429 $325.00
08/29/2009 MILEAGE A0425 $45.85
11/13/2009 PAYMENT $370.85
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 11/18120Q9
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
a V
Bier To: IRENE SOBOTKA ICD -9: 9596 E8888
4650 W 121ST ST
ZIONSVILLE, IN 46077
From: 12999 N PENNSYLVANIA APT /SUITE# 106
To: ST. VINCENTS HOSPITAL
1
Patient: IRENE SOBOTKA
4650 W 121 ST ST Insurance
ZIONSVILLE, IN 46077 2
Patient No: 200902208
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$370.85 $0.00 $370.85
CPT
Date Description Charges Credits
08/29/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
0812912009 MILEAGE A0425 $45.85
11/13/2009 PAYMENT $370.85
11/18/2009 REFUND 370.85
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
PLEASE POST PAYMENT: FOR OUR MUTUAL CUSTOMER p,
$370':85
.Account: 2Q0902208 4` 1�i. 9561214
Please: Ditect.:Any Questions
To. s„ 442��sa 000099500:1
E BILL
g CA�ITAL ONE.- ONLIN PAY
ti IRENE R S0 0TKA
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4 w 121ST ST Flovember 10 2009'
u 210NSVI:LLE IN 46Q77 CAPITAL ONE N A
DOLLARS
Pay THREE HUNDRED SEVENTY`AND *85 1:100
370:85
CARMEL FIRE DEPT Void After 180 DAYS
To
j The 2 CIVIC SQ Signature DAY
CARMEL IN 46032 -2584 This check has been authorized
Order b our depositor;;:
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Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or 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.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
e'
o
Total 7Q Y6
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.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
z/ t%ll e �1y 7 7
2 70. F,6
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I 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 1 Y
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund