207907 04/10/2012 CITY OF CARMEL, INDIANA VENDOR: 364693 Page 1 of 1
c• ONE CIVIC SQUARE IN UFCW UNIONS 8 FOOD EMPLOYEES
CARMEL, INDIANA 46032 PO Box 42666 CHECK AMOUNT: $523.32
INDIANAPOLIS IN 46242 CHECK NUMBER: 207907
CHECK DATE: 411 012 01 2
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 523.32 OTHER EXPENSES
Date: 03/26/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederaIID# 356000972
ACCOUNT HISTORY
Bill To: JEFFREY G SWANK IcD -9: 78009 2930 2512 E8160
141 2ND AVE NE
CARMEL, IN 46032
From: 116TH &GUILFORD
To: ST. VINCENTS HOSPITAL
1 ANTHEM BLUE CROSS BLUE
Patient: JEFFREY G SWANK UFI000022054
141 2ND AVE NE Insurance
CARMEL, IN 46032 2
Patient No: 201102636
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW THANK YOU.
Total Amount Total Paid Balance
$523.32 $1,046.64 52132
CPT
W n»l rs u yM1' i t' i
I m95,w n O N Oi h1 tl Y r 1 i 7 iN iW P 3m a neug. v N m
iDate enfle .��u ri ll Charges 'htf r Credtts k'i
��l �.�k i,k,,sM
09/29/2011 ADVANCED LIFE SUPP i —EMBR A0427 $4�5,00
09/29/201: MILEAGE A0425 $48.32
11/01/2011 COMMERCIAL INSURANCE PP_YMENT $523.32
03/20/2012 COMMERCIAL INSURANCE— PAYMENT $52-32
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL. 1999
Date: 03126/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 Federalm# 356000972
ACCOUNT HISTORY
Bill To: JEFFREY G SWANK ICD -9: 78009 2930 2512 E8160
141 2ND AVE NE
CARMEL, IN 46032
From: 116TH &GUILFORD
To: ST. VINCENTS HOSPITAL
I ANTHEM BLUE CROSS BLUE
Patient: JEFFREY G SWANK UFI000022054
141 2ND AVE NE Insurance
CARMEL, IN 46032 2
Patient No: 201102636
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW THANK YOU.
Total Amount Total Paid Balance
$52132 $52132 $0.00
CPT
1� pIp 1 0 n V ku rr -t rd'GP xJlr A y w' v, i nP rye. n 4 r N r'� P e�t�xr +e y mid 's4 r I p
Date 4iGA r 1 4r,'IrlcE i DOSCIIPtIOn L� 2 c�W� a,u is y I'I I d J o 'o C.tla�QCS 1 1� k� BdltS gs.
09/29/2011 ADVANCED LIFE SOPF 1 -EMER A0427 =75.00
09/29/2011 MILEAGE A0425 548.32
11/01/2011 COMMERCIAL INSOR.ANCE PAYMENT $523.32
03/20/20 COMMERCIAL INSURANCE PAYMENT $523.32
03/26/2012 REFUND 523.32
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Farm No. 201 (Rev. 1995)
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
[�rdI I LLrbonS ii- "oy ClkQA iiii Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
e;mb s i OkWagi a& 33
I
Total 32
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 NS. WARRANT NO._
ALLOWED 20
IN SUM OF 5a3, 3z
�i ro:gax Li2&49
G.s q2
5� 3Z
ON ACCOUNT OF APPROPRIATION FOR
4mhala CC
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
R
is
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund