215787 12/18/2012 „Mf CITY OF CARMEL, INDIANA VENDOR: 366756 Page 1 of 1
ONE CIVIC SQUARE U S A A GENERAL INDEMNITY COMPA
CARMEL, INDIANA 46032 PO BOX 33490 HECK AMOUNT: $1,369.37
o� SAN ANTONIO TX 78265 CHECK NUMBER: 215787
CHECK DATE: 12/18/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4351000 26201 022465741-4 1, 369 . 37 6/4/2012
IN 9800 Fredericksburg Road
:is qg
San Antonio,Texas 78288
USAW
CITY OF CARMEL PD December 12, 2012
3 CIVIC SQUARE
CARMEL IN 46032-2584
Action Needed: Reimbursement of Payment
Dear Sir or Madam,
On July 19, 2012, we issued a payment to you in the amount of $1,369.37 in error for the claim
referenced below:
Policyholder: Kenneth Clesen
Claim #: 022465741-4
Date of loss: June 4, 2012
Loss location: Indianapolis, Indiana
We're asking that you reimburse us for the payment. Please use the enclosed form when returning
the overpayment, and include your claim number and date of loss on your check or money order.
Contact us to arrange making installment payments if you're unable to forward the entire amount.
If we do not hear from you within 30 days, we'll be forced to assign this matter for collections.
If you have questions, please call a member service representative at 1-800-531-USAA (8722).
Sincerely,
��4-e j654-y��
Jennifer Rodriguez
Injury Operations - SAT
USAA General Indemnity Company
PO Box 33490
San Antonio, TX 78265
Phone: 1-800-531-8722, Ext. 61535
Fax Phone: 1-800-531-8669
Enc: Payment Remittance Form - 88290
022465741 - DM-01776 -4 - 6844 - 10 54555-0612
Page 1 of 1
022465741 - 4
Payment Remittance Form
Please enclose this form with your payment
Policyholder: Kenneth Clesen
Reference #: 022465741-7101-4-6844
Date of loss: June 4, 2012
Amount owed: $ 1,369.37
Amount enclosed: $
Your name:
Address:
Home phone:
Business phone:
Thank you for your payment.
Return this form to: 0027 P&C Claims Shared Services
ASA II COE
9800 Fredericksburg Road
San Antonio, Texas 78284-8499
88290-0508
MAIL DIRECT
03292 . M2G6 . JSS430330400 . 01 . 01 . 484 RECEIVED
CITY OF CARMEL PD
ATTN: VICKI BAILEY
3 CIVIC SQUARE JUL 2 3 2012
CARMEL, IN 46032
CARMEL POLICE DEPT
USAA General Indemnity Company
PO Box 33490
San Antonio, TX 78265
INVOICE #: USAA-41570224606397036080 LOB: AUT
USAA # : 022465741 CLAIMS REP: 06844-10
LOSS RPT # : 4 CHECK # : 0003246835
LOSS DATE: 06/04/2012 CHECK DATE: 07/19/2012
POLICYHOLDER:
KENNETH CLESEN
EXPLANATION OF PAYMENT TOTAL PAYMENT AMOUNT
Payment under Property Damage Liability Coverage City $**1 , 369. 37
of Carmel PD, 2009 CHEVROLET IMPALA LS
93868-1209
18433-0709
p .o o m It; •v!'Sdof�Lr o�oS3�':• a s u° Y cTS o Rrff7 AAA7 05 1
�Iy!'+, USAAI General) Indemnity Company DATE
IIIht� Poi 'Box 33490, 07/19/2012
VuII,II ' iSanl''Antonio, TX 78265
CHECK. AMOUNT
$**1, 369. 37
PAY **One Thousand Three Hundred Sixty:-Nine and 37/100 s**
TO , CITY OF CARMEL PD
THE,-
ORDER
OF - fq,n .''I,III, *,,11^•Pp"';'?�;��Ildlll,., ,:�°ip�l„ �''a'"'^l°"liill',I,I
I
USAA #: 022465741 I LR #: 4 a li 1 ullillllli;ill5
I II SS I I Illh `i� �1�111iil hL�i ��ill 111!111' iIg44�g1��'ilill l�II�I��.,
., iil.,,.. '•:e!i .I rc�, L,:„oo,I!�I�III, $ �+,III II,III,IIIII J�IIy,�}�, II IIIIIMV
NATURE OF PAYMENT: r o
Payment under Property Damage Liability Coverage City of Carmel PD, 2009 h ,III v i;ll
CHEVROLET IMPALA LS *Si1,i',uiIIIIIiIPIII'I
BANK OF AMERICA - HARTFORD, CT VOID 180 DAYS FROM ISSUE DATE AUTHORIZED SIGNATURE'"
11'000 3 2 4 68 3 511' 000 b b90044Si: 2 2400 LS66S11°
C 0 INDIANA RETAIL TAX EXEMPT PAGE
1t , ®f C CERTIFICATE NO.003120155 002 0� PURCHASE ORDER NU:MBER
j FEDERAL EXCISE TAX EXEMPT
=1
35-60000972
ONE CIVIC SQUARE , THIS NUMBER MUST APPEAR ON INVOICES,A/P
CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL- 1997 SHIPPING LABELS AND ANY CORRESPONDENCE.
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
ISMrAl2
HUbIQP ExpFoss Co : Ion Camel Policy Dopartmont
VENDOR
SHIP 3 CIVIC square
503 Wo @I Drivo yy TO Cumol, IN 466
Ca ol„ IN 4M (317)671
CONFIRMATION BLANKET CONTRACT PAYMENTTERMS FREIGHT
QUANTITY UNIT OF MEASURE V DESCRIPTION UNIT PRICE EXTENSION
Account 43-610.00
9 Each repairs to vehicle $1,369.37 $1,369.37
Sub Total: $1,369.37
_ wed R_,✓, -•,,....,'... �� ` ,
,� ® d • A f'
car 43/Robbing
Send Invoice To:
Carmel Pollce Departmont
Attn. Toresa Anderson
3 Civic Squam
Car mol, IN 46== PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
Carmel Police Dept. PAYMENT $1,39.37
• A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT HERE IS AN UNOBLIGATED BALANCE IN
•SHIP REPAID. THIS APPROP�A FFICIENT TOPAYFOR.T.HE ABOVE ORDER.
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED.
•PURCHASE ORDER NUMBER MUST APPEAR ON.ALL ORDERED BY
SHIPPING LABELS. '� Q p
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE b (�° �l IPa `�
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
®� CLERK-TREASURER
DOCUMENT CONTROL NO. A.P.V. COPY-SIGN AND RETURN TO.CLERK'S OFFICE
VOUCHER NO._.__...__..._....____ WARRANT NO..______...___
ALLOWED 20
-- __-. IN THE SUM OF$
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or .
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__.._______
• t
20
...........__............................_.............................__. _. -----------------------.......................--
Signature
-_....._.__....................
......__.........__...._._........__........._....._......_.............._.._............._...._...........__. —
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
VOUCHER NO. WARRANT NO.
ALLOWED 20
USAA General Indemnity Company
IN SUM OF $
P.O. Box 33490
San Antonio, TX 78265
$1,369.37
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#rrITLE AMOUNT Board Members
26201 I 022465741-4 I 43-510.00 I $1,369.37 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
Wednesday, December 12, 2012
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12/12/12 022465741-4 duplicate payment $1,369.37
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