HomeMy WebLinkAbout210933 07/17/2012 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
0 ONE CIVIC SQUARE PAMELA LISTER CHECK AMOUNT: $105.35
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE
ri6�fig`. CARMEL IN 46032 CHECK NUMBER: 210933
CHECK DATE: 7/1712012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 105 . 35 TRAVEL PER DIEMS
Prescribed by State Board of Accounts MILEAGE CLAIM General Form No.101 (1955)
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(Governmental nit) / /,
�.��`7 CS �d�� ��/(�A�J On Account of Appropriation No. �� ' Q� for
Office,Board,Departme or Institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE
20 Point Point Start Finish TRAVELED PER MILE
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Auto License No. TOTALS S
* 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.
Date
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows:
IN FAVOR OF
Q'MThat it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon statutory autho:
That it is apparently correct
$ incorrect
On Account of Appropriation No. 7�y Y for
Disbursing Officer
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Allowed 20
in the sum of$ o M.
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