208249 04/25/2012 CITY OF CARMEL, INDIANA VENDOR: 366185 Page 1 of 1
t ONE CIVIC SQUARE COMMUNITY EDUC CHILD ADVOCAC
CARMEL, INDIANA 46032 575 RILEY HOSPITAL DRIVE HECK AMOUNT: $25.00
ROOM #008
CHECK NUMBER: 208249
INDIANAPOLIS IN 46202
CHECK DATE: 4/25/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1096 4239039 CK REQUEST 25.00 GENERAL PROGRAM SUPPL
Carmel i Clay
Parks &Recreation CHECK REQUEST D
Date: 3/27/12 APR 1 8 2012
BY...............
Check payable to
Name: Community Education and Child Advocacy Department
Address: 575 Riley Hospital Drive, Room #008
City, State, Zip Indianapolis, IN 46202
_X Mail check to payee Return check to requestor
Check Amount 25.00 Date Required 12 7 l 10
Check needed for Refundable deposit for supplies borrowed for Carmel Clay Safety Town
To be paid from
PO (if applicable) MC002750
Budget account GL 1096424239039
Budget Line Description Youth General Program Supplies
Invoice(s) and Purchase Order (if required) MUST be attached.
Requested by (print): y on
Requested by (signature):
Approved by (signature of Division Manager):
on this date
Form revised 7 -7 -08 Shared Forms Business Services Check Request Form Check Request (rev 7 -7 -08)
i
TERMS OF AGREEMENT
Riley Hospital for Children at Indiana University Health
Community Education and Child Advocacy
IU School of Medicine
Injury Prevention Resources
The Community Education and Child Advocacy Department of Riley Hospital for
Children's mission is to help all children grow up to lead healthy, safe, and productive
lives. To help accomplish this mission, the Department offers certain resources to
community partners and educators to assist them in their efforts to promote injury
prevention to all children.
The Department, in providing these resources for loan, agrees to:
1. Maintain and keep in good repair resources•to assure that all materials are provided to
the borrower intact, complete, and /or ready for use;
2. Maintain contact and due date information on all borrowers to assure the prompt
return of all loaned resources.
In turn, the Borrower agrees to:
1. Complete and sign this Terms of Agreement form.
2. Maintain the condition of the resource during the loan period. The Borrower agrees
to provide the funding necessary to replace and /or repair a resource should the
resource become damaged, broken, or lost during the loan period.
3. Pre -pay a refundable cash deposit of $25 to cover minor damages during the
borrowing period. In the event the resources are returned needing repairs the
Department will undertake the repairs and refund any unused portion of the deposit.
In the event the repairs are more than the deposit an invoice will be sent to the
borrower for the balance owed.
4. Return the resource by the due date set by the Department. Materials typically are
loaned for 2 -3 days. Repeated failure to return a resource by the due date prevents
others from being able to use the resources and will restrict the future borrowing
privileges of the Borrower.
The Department and Borrower agree to the above terms.
Community Education Borro er �,�L,�l w.. k►. �c
and Child Advocacy Department
Riley Hospital for Children
date date
N� i
Resources Borrowed: (please list below) Period of Loan
4 —12 inch bikes 6/12/12 6/14/12
from to
4 —16 inch bikes
1 20 inch bike
12 large traffic cones
11 traffic signs
Borrower Contact Information (please print):
Name: Lindsay Atkinson
Title: Youth Recreation Supervisor
Organization: Carmel Clay Parks Recreation
Day Phone: (317) 573 -5247 Fax (317) 573 -5254
e -mail: lleber @carmelclayparks.com
Department Contact Information
Community Education and Child Advocacy Department
Riley Hospital for Children at IU Health
575 Riley Hospital Drive, Room #008
Indianapolis, Indiana 46202
317- 944 -2964 (ph); 317 948 -3221 (fx)
www.riteysafe,tNstore.org
www.racin fob rsafety.or
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.
Community Education and Child Advocacy Terms
575 Riley Hospital Drive, Room 008
Indianapolis, IN 46202
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
3/27/12 Ck Request Supplies for Carmel Clay Safety Town 25.00
Total 25.00
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.
Community Education and Child Advocacy Allowed 20
575 Riley Hospital Drive, Room 008
Indianapolis, IN 46202
In Sum of
25.00
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1096 -42 Ck Request 4239039 25.00 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
19 -Apr 2012
P &M
Signature
25.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund