215093 12/04/2012 \�f CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $58.20
CARMEL IN 46032 CHECK NUMBER: 215093
CHECK DATE: 12/4/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 58 .20 TRAVEL PER DIEMS
Prescribed by State Board of Accounts General Form No.101 (1955)
MILEAGE CLAIM a /I,,
Al Yl TO �>U—�F (2k(S;N Sp ,Y r— ; ' DR.
(Governments nit)
On Account of Appropriation No. q-36 -67
- Offlce,Board,Department or Institution
DATE 'FROM TO ODOMETER READING` NATURE OF BUSINESS AUTO MILES MILEAGE
20 a Point Point Staff Finish TRAVELED PER MILE
0 Zfiei— D O'I D i J Pr
V` `r � VV Z 0 / 0 7 t1 -3
0 h 3
,z
LJ
.� \A ti- 1:- ev D t ti
AA :-'� t� ul
"�- vl �� �� /d(o7 /d
Auto License No. TOTALS () 02b
" 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 cl ' ally du after
allowing all just credits, and that no part of the same has been paid.
Date
Claim No. Warrant No. I have examined the within claim.and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
That it is duly authenticated as requi
_ . by law;
- _ - - That it is based upon'statutory,author
correct
;. That it is apparently incorrect
$ �"�!ac
On Account of Appropriation No, for
isb -
- D ursin g Officer
-
n
Allowed . ... .. 2d
_ . in the sum of$ - - - o (D.
- - (13oCad or Commission)
L M
FILED - .
(Official Title)
. O
y