213898 10/23/2012 CITY OF CARMEL, INDIANA VENDOR: 366649 Page 1 of 1
ONE CIVIC SQUARE TIMOTHY DINES CHECK AMOUNT: $95.00
CARMEL, INDIANA 46032 18201 EMMA CIRCLE
WESTFIELD IN 46062 CHECK NUMBER: 213898
CHECK DATE: 10/23/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1092 4358400 95 . 00 PARKS DEPARTMENT REFU
GLOBAL REFUND RECEIPT
Receipt# 962902
Carmel 1D Clad Payment Date: 10/19/12
Parks&Recreatioh R.E CETX7ED Household M 38409
OCT 19 2012
Monon Community Center $Y: Timothy Dines Hm Ph: (317)867-3293
Carmel IN 46032 18201 Emma Circle Wk Ph: (765)675-5201
Westfield IN 46062 Cell Ph:(765)437-1402
tdines @msn.com
Phone: (317)848-7275
Fed Tax ID#35-6000972
Pass Details
CANCELLATION -Refund Of 95.00
Pass Holder: Timothy Dines Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: MC HH Mthly(M MCHHM),#126300 855.00 0.00 0.00 855.00 0.00
Valid Dates: 01104/2012 to 01103/2013 (Pass Cancellation)
Cancellation Effective: 10/19/2012
CANCELLATION
Pass Holder: Kathryn Dines Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: MC HH+ (M MCHH+), #126301 0.00 0.00 0.00 0.00 0.00
Valid Dates: 01/04/2012 to 01/03/2013 (Pass Cancellation)
Cancellation Effective: 1011912012
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 adullt supervision.
Children must be age 14+to utilize the Fitness Center without adult supervision.
CANCELLATION
Pass Holder: Jacob Dines Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: MC HH+ (M MCHH+),#126302 0.00 0.00 0.00 0.00 0.00
Valid Dates: 01/04/2012 to 01/03/2013 (Pass Cancellation)
Cancellation Effective: 10/19/2012
CANCELLATION
Pass Holder: Zachary Dines Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: MC HH+ (M MCHH+),#126303 0.00 0.00 0.00 0.00 0.00
Valid Dates: 01/04/2012 to 01/03/2013 (Pass Cancellation)
Cancellation Effective: 10/19/2012
CANCELLATION
Pass Holder: Glace Dines Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: MC HH+ (M MCHH+), #126304 0.00 0.00 0.00 0.00 0.00
Valid Dates: 01/04/2012 to 01/03/2013 (Pass Cancellation)
Cancellation Effective: 10/19/2012
Page# 1 of 2
'�° GLOBAL REFUND RECEIPT
Carmel -+�` Receipt# 962902
Parks&Recreation Payment Date: 10/19/2012
Household#: 38409
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 10/19/12 @ 11:33:07 by KLB FEES CHANGED ON CANCELLED ITEMS(+) 950.00-
SURCHARGE APPLIED AGAINST CANCELLED FEES(-) 855.00-
NET AMOUNT'FROM CANCELLED.ITEMS
TOTAL AMOUNT REFUNDED 95.00
NEW NET HOUSEHOLD BALANCE 0.00
Refund of=_> 95.00 Made By==>REFUND FINAN With Reference==>cancelled 10/4/12
All refunds are subject to State Board of Accounts claim procedure and may t ke - eeks o process. A check will be
issued. No cash or credit card refunds.
10/19 IZ
Authorized Signature Date Au t on d Si nat a date
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.
JO 92.
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.
Dines, Timothy Terms
18201 Emma Circle Date Due
Westfield, IN 46062
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
10/19/12 962902 Refund $ 95.00
Total $ 95.00
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.
Dines, Timothy Allowed 20
18201 Emma Circle
Westfield, IN 46062
In Sum of$
$ 95.00
ON ACCOUNT OF APPROPRIATION FOR
109 -Monon Center
PO#or INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Dept#
1092 962902 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
19-Oct 2012
4jChh11nrYW-,7,,
Signature
$ 95.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund