HomeMy WebLinkAbout177769 09/29/2009 CITY OF CARMEL, INDIANA VENDOR: 359164 Page 1 of 1
ONE CIVIC SQUARE KEN MILLER
CARMEL, INDIANA 46032 768 GRACE COURT CHECK AMOUNT: $85.80
'1, Ii o H �a CARMEL IN 46032 CHECK NUMBER: 177769
CHECK DATE: 9129/2009
DEPAR TMENT ACC PO NUM INVOICE NUM AMOUN DESCRIPTION
1207 4343004 187892 85.80 MILEAGE
Prescribed by State Board of Accounts
MILEAGE CLAIM
General Form No. 101 (1955)
TO
DR.
(Governmental Unit
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
8 v
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S -15 o
-2- 7 r�
IQ 1
0
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Auto License No. 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
Claire 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 required
°l by law;
That it is based upon statutory aruthority;
correct
That it is apparently incorrect
On Account of Appropriation No. for
Disbursing Officer
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