The URL can be used to link to this page

Home My WebLink About208249 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