209604 06/05/2012 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
0 ONE CIVIC SQUARE PAMELA LISTER CHECK AMOUNT: $67.63
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE
CARMEL IN 46032 CHECK NUMBER: 209604
CHECK DATE: 6/5/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 67.63 TRAVEL PER DIEMS
Prescribed by Slate Board of Accounts MILEAGE CLAIM General Form No. 101 (1955)
TO
C o dl (Gover n nmental nit)
1= /[s h On Account of Appropriation No, ye0 O for i i
(Office, Board, Department or Institution
DATE FROM TO
ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE
20 Point Point Start Finish TRAVELED PER MILE
Vk
37A d
u
K7
7 5-q 3 %L 3
S s /d2 �n q 3 DIP k
Auto License No. TOTALS I (p�
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
3/
Date
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows;
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon statutory author correct
�OJ That it is apparently incorrect
On Account of Appropriation No. for
i
Disbursing Officer
CQ
O
Allowed 20
in the sum of
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(Board or Commission)
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(Official Title)
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