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HomeMy WebLinkAbout215915 12/25/2012 CITY OF CARMEL, INDIANA VENDOR: 366803 Page 1 of 1 ONE CIVIC SQUARE SUSAN WYMAN CARMEL, INDIANA 46032 13180 FOSTER COURT CHECK AMOUNT: $333.22 CARMEL IN 46033 CHECK NUMBER: 215915 CHECK DATE: 12/25/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 333 .22 REFUND r r' +I W ® .O © i CITY 06 , 1 "'ARMEL JAmEs BRAINARD, MAYOR December 17, 2012 Susan Wyman 13180 Foster Court Carmel, IN 46033 RE: INVOICE #201203300 D.O.S. 10/13/2012 Dear Susan Wyman: Enclosed you will find a reimbursement check in the amount of$333.22. On November 27, 2012 we received your payment for $416.53 and Anthem paid on December 11, 2012 $333.22. Coinsurance amount $83.31 and the credit balance of$333.22 is your refund. If you have any questions, please feel free to contact me at (3 17) 571-2604. Sincerely, Michelle T. Harrington Billing Administrator CARAIEL FIRE DEPARTA'LENT STEVEN A. COUTs HEADQUARTERS Two CIVIC SQUARE, CARNIEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615 ------------------------------_------------------------------------------------------------------------------------------------—----------—----------- Return this portion with your payment Payable To 201203300 SUSAN S,.WYMAN. by O ti; ;,4 $416.53 Run Date 10/13/2012 Amount Paid-L] 16. -3 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL,1999 THOMAS'P.WY_MAIV SUSAN S:;WYMAN ;F69 ER CT. CARMEL,`IN 46033 Date' a _ 'Pay.to the 'Order ofn � —k ! ;,Q/ � 1�l!�L1 = Memo -- -- - r. svr. .„.a..•r�'�. •s V �� �r S :`�.•'�w fF d'�...' a+..'en.. z� sr� rr iit u 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 2012 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund