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213999 10/23/2012 CITY OF CARMEL, INDIANA VENDOR: 366650 Page 1 of 1 ` ONE CIVIC SQUARE PAUL LEWANDOWSKI CHECK AMOUNT: $95.00 CARMEL, INDIANA 46032 909 PRESTON DRIVE .off a� INDIANAPOLIS IN 46280 CHECK NUMBER: 213999 CHECK DATE: 10/23/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1092 4358400 95 . 00 PARKS DEPARTMENT REFU GLOBAL REFUND RECEIPT Receipt# 962183 a��'� �=r� � Payment Date: 10/16/12 Household#: 45698 Par sAccreation OCT 16 2012 Monon Community Center , ---- -� Pau! Lewandowski Hm Ph: (317)853-6356 ILL_ _ Carmel IN 46032 909 Preston Drive Wk Ph: (317)853-6356 Indianapolis IN 46280 Cell Ph:(812)624-5735 Lisa.C.Lewandowski @gmaii.com Phone: (317)848-7275 Fed Tax ID#35-6000972 Pass Details CANCELLATION Pass Holder: Paul Lewandowski Fees+Tax Discount Prev Paid Cur Paid Amount Due Pass Type: MC HH+(M MCHH+),#162839 0.00 0.00 0.00 0.00 0.00 Valid Dates: 03/09/2012 to 03/09/2013 (Pass Cancellation) Cancellation Effective: 10/16/2012 Pass Comments: Children must be age 11 or older to utilize the pools and/or gymnasium unaccompanied by an adult. Children ages 11-13 may use Fitness Center, but must be under adulit supervision. Children must be age 14+to utilize the Fitness Center without adult supervision. Cancel Reason: Guest requested suspension through October and was charged in error on October 15th. Check refund request approved. CANCELLATION -Refund Of 95.00 Pass Holder: Lisa Lewandowski Fees+Tax Discount Prev Paid Cur Paid Amount Due Pass Type: MC HH Mthly(M MCHHM),#162838 475.00 0.00 0.00 475.00 0.00 Valid Dates: 03/09/2012 to 03/09/2013 (Pass Cancellation) Cancellation Effective: 10/16/2012 Cancel Reason: Guest requested suspension through October and was charged in error on October 15th. Check refund request approved. CANCELLATION Pass Holder: Erek Lewandowski Fees+Tax Discount Prev Paid Cur Paid Amount Due Pass Type: MC HH+(M MCHH+),#162840 0.00 0.00 0.00 0.00 0.00 Valid Dates: 03/09/2012 to 03/09/2013 (Pass Cancellation) Cancellation Effective: 10/1612012 Cancel Reason: Guest requested suspension through October and was charged in error on October 15th. Check refund request approved. CANCELLATION Pass Holder: Olivia Lewandowski Fees+Tax Discount Prev Paid Cur Paid Amount Due Pass Type: MC HH+(M MCHH+),#162841 0.00 0.00 0.00 0.00 0.00 Valid Dates: 03/09/2012 to 03/0912013 (Pass Cancellation) Cancellation Effective: 10/16/2012 Cancel Reason: Guest requested suspension through October and was charged in error on October 15th. Check refund request approved. Page# 1 of 2 Carmel e Clay GLOBAL REFUND RECEIPT t� Receipt# 962183 Parks&Recreation Payment Date: 10/16/2012 Household#: 45698 PREVIOUS NET HOUSEHOLD BALANCE 0.00 Processed on 10/16/12 @ 15:15:07 by KLB FEES CHANGED ON CANCELLED ITEMS(+) 570.00- SURCHARGE APPLIED AGAINST CANCELLED FEES(-) 475.00- .NET.AMOUNT:fROM:CANCELLED:ITEMS 95'OD ;;<TOTAL':AMOUNI':.REFUNDED ;95 00:;;: NEW NET HOUSEHOLD BALANCE 0.00 Refund of==> 95.00 Made By=_>REFUND FINAN With Reference==> All refunds are subject to State Board of Accounts claim procedure and may take 4-6 weeks to process. A check will be issued. No cash or credit card refunds. Authorized Signature Date uthorize ignat D to Ready for a Family Pool Challenge in Indoor Aquatics?Then pull your swimsuit out from the closet, put on your thinking or swimming cap, and prepare for an evening of excitement, challenge, and family-friendly competition. Join us on Friday, November 2,from 6-9pm, as we build cardboard boats to race and compete in fun relays and games! Finish with open swim while enjoying the waterslides and more with your family. Don't miss out on this perfect family team building night that you'll remember forever!$10/family. Register online at www.carmelclayparks.com (activity#229003-01). Escape Day Passes are non-refundable. I OaZ. L4 3 16L4UJ Page# 2 of 2 ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of 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. Lewandowski, Paul Terms 909 Preston.Drive Date Due Indianapolis, IN 46280 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 10116/12 962183 Refund $ 95.00 Total $ 95.00 I 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. Lewandowski, Paul Allowed 20 909 Preston Drive Indianapolis, IN 46280 In Sum of$ $ 95.00 ON ACCOUNT OF APPROPRIATION FOR 109 - Monon Center PO#or INVOICE NO. ACCT#/TITLE AMOUNT Board Members Dept# 1092 962183 4358400 $ 95.00 1 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 18-Oct 2012 Signature $ 95.00 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund