210398 07/05/2012 CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
ONE CIVIC SQUARE HINCKLEY SPRINGS
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CARMEL, INDIANA 46032 PO BOX 660579 CHECK AMOUNT: $43.93
DALLAS TX 75266 -0579 CHECK NUMBER: 210398
CHECK DATE: 7/5/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4239099 2677859 43.93 OTHER MISCELLANOUS
1- 800 -4- WATERS (1- 800 492 -8377) www.HinckloySprings.com
Upcoming Delivery Dates Hinckiey 6TIMA%
July August September Springs We Deliver!
Bottled Water •Filtration •Coffee
Thursday, 5 Thursday, 2 Thursday, 13
Thursday, 19 Thursday, 16 Thursday, 27 Enjoy premium coffee and tea brands at your home or office.
Thursday, 30 With the addition of Standard Coffee to our service options,
customers can benefit from a complete beverage program
from one delivery source. Learn more at water.com.
Customer Account 17220042677859
KIM ROTT Invoice Date: 06 -23 -12
CARMEL CITY COURT Invoice 2677859 062312
1 CIVIC SQ
CARMEL, IN 46032 Purchase Order
Date Transaction Details Qty. Each Amount
Previous Balance 121.79
06 -07 -12 P209183 Payment Check 209183 Thank You -48.30
06 -08 -12 P209455 Payment Check 209455 Thank You -17.56
Remaining Balance 55.93
R121502494748 WHITE HOT AND COLD COOLER RENTAL 1.0 13.50 13.50
06 -07 -12 T121593042003 HINCKLEY SPRINGS 5G DRINKING WATER 2.0 9.99 19.98
5.0 GALLON BOTTLE DEPOSIT 2.0 6.00 12.00
5.0 GALLON BOTTLE RETURN -4.0 6.00 -24.00
Rec'd By: Not Available or Refused
06 -21 -12 T121733042002 HINCKLEY SPRINGS 5G DRINKING WATER 2.0 9.99 19.98
5.0 GALLON BOTTLE RETURN -2.0 6.00 -12.00
5.0 GALLON BOTTLE DEPOSIT 2.0 6.00 12.00
Rec'd By: Not Available or Refused
06 -21 -12 75697508 ENERGY SURCHARGE 1.0 2.47 2.47
Total New Charges 43.93
"'AS OF YOUR NEXT INVOICE, THE TABLE USED TO CALCULATE YOUR VARIABLE ENERGY SURCHARGE WILL CHANGE, WHICH
MAY RESULT IN AN INCREASE TO THE AMOUNT OF YOUR BILL. PLEASE VISIT WWW.WATER.COM /ENERGYSURCHARGE OR CALL
1- 800 -492 -8377 FOR THE REVISED RATES AND OTHER INFORMATION.
Managing your account is now at your fingertips. Take advantage of many time- saving options
available on water.com. Save paper when you sign up for elnvoice, order additional products,
check your next delivery, pay your bill and much more. Log on today!
30356 -P -0036
Previous Balance Payment Total Neay This Amount
$121.79 $6 w Charges P 5.86 $43.93 $99.86
V Write the comp acco unt number on your check. Detach remittance and mail with payment in the enclosed envelope. To pay online go to www.Hinckle ySprings.com
How to Read Your Statement Important Monthly Promotions:
uaom^y oam., o.ce: We Deliver! Register online for access to your
Delivery Calendar: Mo9 sp„ a wn. account. You can view and pay your bill,
Bs w n w r°he nniqF Fa.pEwry
Your scheduled deliveries for �.�.M check delivery schedule and order
the next three months. products all online.
Customer Account Number: Bottle Deposits:
For prompt service, please use this Highlights bottle deposits and returns.
number when referring to your account. y .E n.
Easy to Pay:
Pay your invoice through the mail, online at
Summary: www.water.com or call us to expedite your
Previous balance and posted remittance with automatic credit card payments
payments since last bill.
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Total New Charges:
This information provides totals for Mail Remittance With Payment To:
various products and transactions. ,aun,m Please detach remittance and mail
m ❑��.Aa a� using business envelope provided.
11.11 1.1.1 LLA 11.1.1�� n 1-1 R.-I.... wlm Iry -T-
Important Monthly Message
Billing Rights Summary Electronic Funds Transfer Notice
In case of Errors or Questions About Your Bill: If you pay by check, it will be converted into an "Electronic Funds Transfer"
If you think your bill is incorrect, or if you need more information about a (EFT), a process in which your financial institution is electronically instructed to
transaction on your bill, write us as soon as possible on a separate sheet, at transfer funds from your account to ours in lieu of processing the check. By
P.O. Box 660579, Dallas,TX 75266 -0579. We must hear from you no later sending your completed check to us, you authorize us to use the account
than 60 days after we sent you the first bill on which the error or problem information therein to create an EFT for the amount indicated on the check. If
appeared. Your bill shall be deemed correct unless disputed within 60 days the EFT cannot be processed for technical or other reasons, you authorize us
from receipt. You can telephone us, but doing so will not preserve your rights. to process an image replacement document, draft, or copy of your check.
In our letter, give us the following information: OPT OUT NOTICE: If you do not wish to participate in this check conversion
Y 9 9 program, please write to us on a separate sheet at:
Your name and complete account number. P.O. Box 660579, Dallas, TX 75266 -0579.
The dollar amount of the suspected error.
Describe the error and explain why you believe there is an error. If you need Insufficient Funds Notice
more information, describe the item you are unsure about. If your check is returned for insufficient or uncollected funds (NSF), your signature
on your check gives us permission to debit your checking account electronically
You do not have to pay any amount in question while we are investigating, but for the uncollected amount. Payment by check constitutes your acceptance of
you are still obligated to pay the amount of your bill that is not in question. While these terms.
we investigate your questions, we cannot report you as delinquent or take any
action to collect the amount you question.
We appreciate your business.
As a food product, bottled water is subject to rules and regulations promulgated by the Federal Food and Drug Administration (FDA).
For further information, please write DS Waters of America, Inc. at P.O. Box 660579, Dallas, TX 75266 -0579.
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
q Purchase Order No.
12. 1 94 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total 3 ,0 �3
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
IN SUM OF
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
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund