215414 12/11/2012 CITY OF CARMEL, INDIANA VENDOR: 359285 Page 1 of 1
ONE CIVIC SQUARE VALESKA SIMMONDS
a CARMEL, INDIANA 46032 2703 E LYNN ST CHECK AMOUNT: $165.38
ANDERSON IN 46016 CHECK NUMBER: 215414
CHECK DATE: 12/11/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4343000 165 . 38 TRAVEL FEES & EXPENSE
PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM 110.IOJ(1986)
MILEAGE CLAIM \616k-c' SIn Mon�
TO
(GOVERNMENTAL UNIT) ON ACCOUNT OF APPROPRIATION NO,_ FOR
(OFFICE,BOARD,DEPART1,1ENT OR INSTITUTION)
DA FROM TO SPEEDOMETER
TE
READING + AUTO MILEAGE
T-- NATURE OF BUSINESS MILES @
POINT POINT START FINISH TRAVELED -7
FER MILE
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M CC =7
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k I rV%Ll
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AUTO LICENSE NO, TOTALS
+ 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 claimed is legally due,after aliowing just credits
and that no part of the same has been paid.
Date
CE',
DEC 4
]3y.
13Y.
PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM No.101(1986)
MILEAGE CLAIM /l le ��I �� t�7.(Jril��('
� � e � TO....
(GOVERNMENTAL UNIT)'Esli. ON ACCOUNT OF APPROPRIATION NO. FOR
(OFFICE,BOARD,DEPARTMENT OR INSTITUTION)
DATE FROM TO SPEEDOMETER
READING + AUTO MILEAGE
MILES
POINT POINT START FINISH NATURE OF BUSINESS T....... PER MILE
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AUTO LICENSE NO. TOTALS
+ 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 claimed is legKly due,after aliow,-.Ag all just credits
and that no part of the same has been paid.
Date
0
q�q s-u 1
DEC 4 2012
BY:
1
I '
i
i
PRFSCRISED BY STATE BOARD OF ACCOUNTS GENERAL FORK 110.101 119861
MILEAGE CL IM I
T i �le.s�(ti Stmnn
_ I
C' �( YEBNMENTAL UNlTt
r ACCOU 4T F APPROPRIATION NO. FOR
1onnh,BOARD,DEPAR71mff OB INsrrnmoN)
DATE FROM TO I SAPEEDDO ETER AUTO MILEAGE
3� l NATURE OF BUSINESS MILES
ED f
POINT POINT START FINISH PER MILE
'l'L �• I1�1�. �) i.�
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I t'
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AUTO LICENSE NO. TOTALS
+ SPEEDOMETER READING columns are to be used only when distance between points cannot be determint d by fix d Mileage or official highway.map. � �C15
i
Pursuant to the provisions and penalties of Chapter 155,Acts 1953,I hereby certify that the foregoing acc unt is ju a d correct, that the amount claimed is lega y due,after allowing all just credits
end that no part of the same has been paid.
tt �` pr 4,JL
Date
1 q
►��" � DEC 42012
I �.
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.
359285 Simmonds, Valeska Terms
2703 E Lynn St Date Due
Anderson, IN 46016
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO# Amount
12/3/12 Reimb Mileage 10/9 - 12/3/12 $ 165.38
f..
Total $ 165.38
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
i
Voucher No. Warrant No.
359285 Simmonds, Valeska Allowed 20
2703 E Lynn St
Anderson, IN 46016
In Sum of$
$ 165.38
ON ACCOUNT OF APPROPRIATION FOR
108 - ESE
PO#or INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Dept#
1081-4 Reimb 4343000 $ 165.38 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
6-Dec 2012
Signature
$ 165.38 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
I