208372 04/25/2012 CITY OF CARMEL, INDIANA VENDOR: 366179 Page 1 of 1
ONE CIVIC SQUARE LIBERTY MUTUAL INSURANCE CO
CARMEL, INDIANA 46032 25762 NETWORK PLACE CHECK AMOUNT: $100.00
CHICAGO IL 60673 -1257 CHECK NUMBER: 208372
CHECK DATE: 4/25/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
801 4347500 MILLER 100.00 GENERAL INSURANCE
Liberty Mutual Surety INVOICE
Invoice Summary MILLER, ADAM C
Balance overdue 0.00 US Dollars
Balance currently due 100.00 US Dollars
Less unapplied funds 0.00 US Dollars
Total due Liberty Mutual Surety by Apr 15, 2012 100.00 US Dollars
Aging of Overdue Balances
Receivable account for US Dollars transactions is current as of Apr 1, 2012
Please direct any questions regarding this invoice to Indianapolis at 317 816 -5800 or Fax 866- 547 -7972.
Liberty Mutual Sur ety INVOICE
Invoice Summary MILLER, ADAM C
Balance overdue 0.00 US Dollars
Balance currently due 100.00 US Dollars
Less unapplied funds 0.00 US Dollars
Total due Liberty Mutual Surety by Apr 15, 2012 100.00 US Dollars
Aging of Ov erd ue Balances
Receivable account for US Dollars transactions is current as of Apr 1, 2012
Please direct any questions regarding this invoice to Indianapolis at 317 816 -5800 or Fax 866 -547 -7972.
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Payment Due By: Apr 15, 2012 Invoice Date: Apr 1, 2012
Total Due: 100.00 US Dollars Amount Paid: `m, .0
Please include advice K paying less than total due.
MILLER, ADAM C LIBERTY MUTUAL INSURANCE CO.
TWO CIVIC SQUARE 25762 NETWORK PLACE
CARMEL IN 46032 CHICAGO IL 60673 -1257
Entity Number: 355394121
04/01/2012 355394121 000000 0104 402000030003990355394121400 SCPCPBNT 00001489 Page 2
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form 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
C j� Purchase Order No.
ovlor'(OA 'a_T� DUa_73- Terms
Date Due
Invoice Invoice Description Amount
P ate Number or note attached invoice(s) or bill(s))
Total
I 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
to
r
�(XD
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
1 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
20 1,k
Z Sig'nat e
Tit
Cost distribution ledger classification if
claim paid motor vehicle highway fund