211369 07/31/2012 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $76.52
CARMEL IN 46032 CHECK NUMBER: 211369
CHECK DATE: 7/31/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 76 . 52 TRAVEL PER DIEMS
Prescribed by Slate Board of Accounts General Form No.101 (1955)
TO-MILEAGE CLAIM / �
(Governmental Unit) m
o On Account of Appropriation No. (4-30 -6 for I _
(Office,Board, Department or Institution
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE @ ��-t-�
20 Point Point Start Finish TRAVELED PER MILE
"7 g
---%-
cl
- _ V�
kA- t, r1S-� 'A 17 1 kg
-AA w M S 3 ("A , 117 g
S 4 7 -3 da C
- w 9 ao 151q 1091'__)q6
Auto License No. TOTALS / 02
* 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 ' legally due, after
allowing all just credits, and that no part of the same has been paid.
Date
t
Claim No. Warrant No. I have examined the within claim and
hereby certify as follows;
IN FAVOR OF
That it is in proper form;
L; That it is duly authenticated as requi
by law;
That it is based upon statutory autho:
�� S-a That it is apparently {incorrect
On Account of Appropriation No. for
Disbursing Officer
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O
Allowed 20 M g
Cr
in the sum of $ o
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(Board or Commission)
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