208726 05/10/2012 CITY OF CARMEL, INDIANA VENDOR: T357065 Page 1 of 1
ONE CIVIC SQUARE HUMANA
CARMEL, INDIANA 46032 PO BOX 14601 CHECK AMOUNT: $355.57
LEXINGTON KY 40512 7478 CHECK NUMBER: 208726
CHECK DATE: 5110/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 355.57 OTHER EXPENSES
CI AI�IVIEL
JANIEs BRr \INA2D, NLWOR
May 2. 2012
Humana
P.O. 13ox 14601
l.exim- KY 40512 -4601
RE Yicather Wo I1) 01.053573201. Grp 628647 DOB 03/11/1984
I)car Sir /Madarn:
'.nclosed you will find a reimbursement check in the amount of $355.57.
On March 6 2012 we received a check from you in the amount of $355.57 for
,/Is. IA/ o jdyla's ambulance transport on January 23, 2012. On April 24, 2012 we received a
check l7rom Allstate in the arnount of Since State Farm is primary, we are
issuing you a refund of $355.57. If you have any questions, please feel free to contact me
Lit O 17) 571 -2604.
Sincerely,
Michelle T. 1- farrinot:on
151'llin Administrator
CAf i i. FiRL Di PAPTiMUNIT
S A. Coins H -.m)Quwt,
TV70 CIVIC SQUARF, CARmo,, IN 46032 Orricr_ 317.571.2600, FAx 31.7.577.2675
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
to I"
Total 5 C
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.
ALLOWED 20
1�afa o ai,45 O SUM OF
X555
ON ACCOUNT OF APPROPRIATION FOR
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
MAY' 7 201
r
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund