215660 12/18/2012 CITY OF CARMEL, INDIANA VENDOR: 131130 Page 1 of 1
0 ONE CIVIC SQUARE HINCKLEY SPRINGS
CARMEL, INDIANA 46032 PO BOX 660579 CHECK AMOUNT: $54.45
o� DALLAS TX 75266-0579 CHECK NUMBER: 215660
CHECK DATE: 12/18/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1301 4239099 120812 54 .45 OTHER MISCELLANOUS
1-800-4-WATERS (1-800-492-8377) www.HinckleySprings.com
Upcoming Delivery Dates Hinckiey V V
Springs We Deliver!
December January February Bottled Water• Filtration • Coffee
Wednesday, 19 Wednesday, 16 Wednesday, 13 Buy any available flavor of Arnold Palmer Sticks(30ct)
or AriZona Tea Sticks(30ct)at$13.99 and get
a case of.5 liter water bottles for FREE (24 bottles/case)
Ask your RSR or call 800.4.WATERS to order today!
Offer Expires 12/28/12
Customer Account#: 17220042677859
KIM ROTT Invoice Date: 12-08-12
CARMEL CITY COURT
1 CIVIC SQ Invoice#: 2677859 120812
CARMEL, IN 46032 Purchase Order#:
Date Transaction# Details Qty. Each Amount
Previous Balance 122.23
11-26-12 P214326 Payment-Check-214326-Thank You -56.81
Remaining Balance 65.42
R123182494748 EVEREST BLACK HOT AND COLD COOLER WITH CUP_ 1.0 11.25_ 11.25-
11-21-12 7123263042044 HINCKLEY SPRINGS 5G DRINKING WATER 4.0 9.99 39.96
5.0 GALLON BOTTLE DEPOSIT 4.0 6.00 24.00
5.0 GALLON BOTTLE RETURN -4.0 6.00 -24.00
ENERGY SURCHARGE 1.0 3.24 3.24
Rec'd By: Not Available or Refused
Total New Charges 54.45
Managing your account is now at your fingertips. Take advantage of many time-saving options
available on water.com. Save paper when you sign up for elnvoice,order additional products,
check your next delivery,pay your bill and much more. Log on today!
30356-P-0037
Previous Balance Payment Total New Charges ° Pay This Amount
$122.23 $56.81 $54.45 ' ° $119.87
Write the complete account number on your check.Detach remiriance and mail with payment in the enclosed envelope.To pay online go to WWW.HinckleySprings.com 0
How to Read Your Statement 1 8004 WA*Eas Important Monthly Promotions:
'.' 9°"'14P D-1 we Deliver' ^ Register online for access to your
m�.zow M°��009 Mugu�n 3009E•°"•_°�� account.You can view and pay your bill,
Delivery Calendar: M� M o w F�n a °
Your scheduled deliveries for ° ' ° '" M° 'ea°,"°tee°m�a�; check delivery schedule and order
the next three months.
"``'° products all online.
Customer Account Number: Bottle Deposits
For prompt service,please use this 1z o—, �,°„ o P Highlights bottle deposits and returns.
number when referring to your account. .E„ Po
Tft
Easy to Pay:
TT, Pay your invoice through the mail,online at
Summary: „a „. s"•,., www.water.com 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 Mail Remittance With Payment To:
various products and transactions. Please detach remittance and mail
❑�,;;ro � ❑ ;�- s using business envelope provided.
H.'ll Hid
Important Monthly Message =,a"'
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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
P.O.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 a the amount of our bill that is not in question.While for the uncollected amount. Payment by check constitutes your acceptance of
Y 9 pay Y q these terms.
we investigate your questions,we cannot report you as delinquent or take any
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 City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
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
pd f�j Ck le Al rO s Purchase Order No.
Pa /3 4 60,5--7 9 Terms
7sa 6o�o " QS7/ Date Due
Invoice Invoice Description Amount
Dat Number (or note attached invoice(s) or bill(s))
12 a o�l�- o tln Gc� e✓ren
Total j
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
S&Z-Itr 6 S
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#!TITLE AMOUNT
DEPT# I hereby certify that the attached invoice(s), or
50 / . , . 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
V Jv� A 20
Si r 9///
le
Cost distribution ledger classification if
claim paid motor vehicle highway fund