214326 11/07/2012 a CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
ONE CIVIC SQUARE HINCKLEY SPRINGS CHECK AMOUNT $56.81
CARMEL, INDIANA 46032 PO BOX 660579
DALLAS TX 75266-0579 CHECK NUMBER: 214326
CHECK DATE. 1117/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4239099 267785910131 56 81 OTHER MISCELLANOUS
1-800-4-WATERS (1-800-492-8377) www.HinckleyS rings corn
Upcoming Delivery Dates Hinckley CTpp_
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October November December 5prnuys We Deliver!
Bottled Water • Filtration • Coffee
Thursday 25 Thursday 8 Thursday 6 We are doubling our commitment to the cause' Athena
Tuesday 20 Thursday 20 announces a minimum contribution of$2 million to support
breast cancer care awareness research and education by
2014 Support the cause by adding a case of Athena to your
order today!
Customer Account#• 17220042677859
KIM ROTT Invoice Date 10-13-12
CARMEL CITY COURT Invoice# 2677859 101312
1 CIVIC SQ
CARMEL, IN 46032 Purchase Order#
Date Transaction# Details Qty. Each Amount
Previous Balance 53.86
10-09-12 P213040 Payment-Check 213040-Thank You -5385
Remaining Balance 000
R122622494748 WHITE HOT AND COLD COOLER RENTAL 1 0 1350 1350
09-21-12 T1 226 5304 201 7 EVEREST BLACK HOT AND COLD COOLER WITH CUP 1 0 000 000
EVEREST BLACK HOT AND COLD COOLER W ITH CUP 1 0 000 000
ENERGY SURCHARGE 1 0 2.98 2.98
Rec d By Not Available or Refused
09-26-12 T122703042077 HINCKLEY SPRINGS 5G DRINKING WATER 3 0 999 2997
CUP PLASTIC FLAT 9 OZ HINCKLEY SPRINGS 50 CT 2.0 369 738
5 0 GALLON BOTTLE DEPOSIT 3 0 600 1800
5 0 GALLON BOTTLE RETURN 3 0 600 1800
ENERGY SURCHARGE 1 0 2.98 2.98
Rec d By Not Available or Refused A
Total New Charges 56.81
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30356-P-0037
Previous Balance Payment Total New Charges Pay This Amount
$53.86 $53.86 $56.81 $56 81
_V Write the complete account number on your check.Detach remittance and mail with payment in the enclosed envelope.To pay online_go to q><nv.HmckleySPrnigs com _�
How to Read Your Statement ' Important Monthly Promotions:
uao—y oeu—y o-: Register online for access to your
Delivery
Calendar-account.You can view and pay your bill,
a check delivery schedule and order
Your scheduled deliveries for °° M° T s x
the next three months. products all online.
Customer Account Number- ttle Deposits.
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For prompt service please use this == Bo
number when referring to your account. Highlights bottle deposits and returns.
, ,�,o,• �" ,� Easy to Pay
" Pay your invoice through the mail,online at
Summary, ,w - www water corn or call us to expedite your
Previous balance and posted remittance with automatic credit card payments
payments since last bill °
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Total New Charges. "
This information provides totals for .� �° .o° ""' m� Mail Remittance With Payment To:
various products and transactions. Please detach remittance and mail
using business envelope provided.
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Important Monthly Message �"'^'Fne os."'*1°9 II.JELL LIJL ullw�I1,n,ll ull III
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Billing Rights Summary Electronic Funds Transfer Notice
In case of Errors or Questions About Your Bill If you pay by check,it will be converted into an 'Electronic Funds Transfer"
If you think your bill is incorrect,or if you need more information about a (EFT) a process in which your financial institution is electronically instructed to
transaction on your bill,write us as soon as possible on a separate sheet,at transfer funds from your account to ours in lieu of processing the check.By
PO Box 660579,Dallas,TX 75266-0579 We must hear from you no later sending your completed check to us,you authorize us to use the account
than 60 days after we sent you the first bill on which the error or problem information therein to create an EFT for the amount indicated on the check. If
appeared.Your bill shall be deemed correct unless disputed within 60 days the EFT cannot be processed for technical or other reasons,you authorize us
from receipt.You can telephone us,but doing so will not preserve your rights. to process an image replacement document,draft,or copy of your check.
In our letter give us the following information. OPT OUT NOTICE.If you do not wish to participate in this check conversion
Y g g program,please write to us on a separate sheet at:
• Your name and complete account number P O Box 660579 Dallas,TX 75266-0579
• The dollar amount of the suspected error
• Describe the error and explain why you believe there is an error If you need Insufficient Funds Notice
more information,describe the item you are unsure about. If your check is returned for insufficient or uncollected funds(NSF),your signature
You do not have to pay any amount in question while we are investigating,but on your check gives us permission to debit your checking account electronically
you are still obligated to pay the amount of your bill that is not in question.While you the uncollected amount. Payment by check constitutes your acceptance of
we investigate your questions,we cannot report you as delinquent or take any these terms.
action to collect the amount you question.
We appreciate your business.
As a food product,bottled water is subject to rules and regulations promulgated by the Federal Food and Drug Administration(FDA).
For further information,please write DS Waters of America,Inc.at P.O.Box 660579,Dallas,TX 75266-0579.
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995)
CITY OF CARMEL
An invoice or 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
/L L� J Purchase Order No
P� T)64 n-s-7 / Terms
1JLT V /- S �s °2�f�_ Date Due
Invoice Invoice Description Amount
.Date Number (or note attached invoice(s) or bill(s))
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Total b
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
ALLOWED 20
14 l�e-��L�i S 1Q1AJ6 5
IN SUM OF $
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$ � -J
ON ACCOUNT OF APPROPRIATION FOR
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Board Members or
D# # INVOICE NO ACCT#/TITLE AMOUNT I hereby certify that the attached invoice(s), or
5 39�� �l5 1 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
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/ at
itle
Cost distribution ledger classification if
claim paid motor vehicle highway fund