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.
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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