216847 01/29/2013 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
0 ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $65.00
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 216847
CHECK DATE: 1/29/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 19343 65 . 00 MEDICAL FEES
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
C Carmel Clay Parks& Recreation/CARMELPARK
1411E 116th Street Terms
Carmel, IN h Street D �12/05/2012
m Invoice#
Date Employee Description Amount I Balance Due
11/29/12 Hammons Jennifer L. Hepatitis B Vaccination#3 $65.00 65.00
In ection Fee $0.00 $0.001
Total Charges-> 1 $65.00
Total Payments&Balance Due-> $0.00 1 $65.00
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35-2079797 S from invoice
Balance due 15 day
date
Purchase n / �S
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Purchaser Date '
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.
00350364 Public Safety Medical Services Terms
324 E. New York Street, Ste 300
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO# Amount
12/5/12 19343 Medical fees $ 65.00
Total $ 65.00
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
Voucher No. Warrant No.
00350364 Public Safety Medical Services Allowed 20
324 E. New York Street, Ste 300
Indianapolis, IN 46204
In Sum of$
$ 65.00
i
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO#or INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Dept#
1081-99 19343 4340700 $ 65.00 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
24-Jan 2013
Signature
$ 65.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund