215870 12/25/2012 - CITY OF CARMEL, INDIANA VENDOR: 366804 Page 1 of 1
ONE CIVIC SQUARE ALEX TAG GROUP CHECK AMOUNT: $244.44
CARMEL, INDIANA 46032 9201 WILSHIRE BLVD#204
BEVERLY HILLS CA 90210 CHECK NUMBER: 215870
CHECK DATE: 12/25/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 244 .44 AMBULANCE REFUND
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CITY`S_OARMEL
_TAMES BRAINARD, MAYOR
December 17, 2012
Alex Tag Group Inc.
9201 Wilshire Blvd #204
Beverly Hill, CA 90210
RE: INVOICE #201202275 D.O.S. 07/12/2012
Dear Alex Tag Group Inc:
Enclosed you will find a reimbursement check in the amount of$244.44.
On November 20, 2012 we received a payment for $407.40 and the amount
due was $162.96. Since you over paid this invoice, I am issuing you a refund of$244.44.
If you have any questions, please feel free to contact me at (3 17) 571-2604.
Sincerely,
�1ell�
Michelle T. Harrington
Billing Administrator
CARREL FIRE DEPARTDQENT
STEVEN A. COUPS HEADQUARTERS
Two CIV(C SQUARE, CARNIEL, IN 46032 OFFICE 317.571.2600, FAN 317-571-2615
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Carmel Fire Department 11/9/2012
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- Insurance Services Insurance Services
HTH Worldwide Insurance Services
PO Box 968 Underwritten by
Horsham, PA 19044 HM Life Insurance
Address Service Requested Company p
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7883 1.5458 MB 0-401 For Customer Service Call:
Jill I J.l 1111111111111111111111111111 111 J i l.r 1111111 888-243-2358
CARMEL FIRE DEPARTMENT 211 z
2 CIVIC SQUARE w
CARMEL, IN 46032-2584
Date: 11/26/12
RECEIVE? DEC 0 4 2612 Provider Number: 282070
Dates)°r Proc !1 (filed Credit Non-Allowed Deductible/ Paid Patient
Services Cnde Svcs Network Amount Code Amount 'Ode Coinsurance Amount Responsibility
Pafient Name: ALFXANDRE TAGLIANt
Patient Number: 201202275 Insured ID: H500920395 Claim Nigmber:;:A]61829°7000
071212 071212 A0427 I 475.00 1 73.94 G 160.42 240.64 160.42
071212 071212 A0425 I 9.06 2.72 G 2.54 3.80 2.54
Totals IR4.06 1 76.601 162.961 244.441 162.96
Billed Non-Allowed Deductible/ Paid Patient ,
Amount Amount Coinsurance Amount Responsibility
Statement Totals 484.06 76.66 162.96 244.44 162.96
Explanation of Message Codes/Network
G The amount shown was considered on a previous claim;therefore, it is not eligible for payment.
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PAY Two Hundred Foety.Four&.44/100 Dollars .
VOID AI'"I'GR 6 MON"I'I-IS
TO THE
ORDER OF,CARN1et,FIRE DEPARTNILN'r
2 CIVIC SQUARe
CARMEL,IN 46032 C�fi'�T✓V
Authorized Signature
'–DU NOT.CASH;IF WAT.ERMARK.'IS:NOT PRESENT OMTHE REVERSE SIDE-OF THIS':DOCUMENT:'c-HOLD AT-:AN-ANGLE,TO'.VIEW
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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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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
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
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
DEC 17 20:12
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund