HomeMy WebLinkAbout217104 02/13/2013 CITY OF CARMEL, INDIANA VENDOR: 00351483 Page 1 of 1
ONE CIVIC SQUARE JOHN CRISLER
CARMEL,INDIANA 46032 13974TH ST CHECK AMOUNT: $200.00
�'+ + SOUTH HAVEN MI 49090
«o„� CHECK NUMBER: 217104
CHECK DATE: 2/13/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 020513 200 . 00 OTHER EXPENSES
Retiree Health Insurance Premium Refund
Authorized by Ordinance D-2123-13
Plan Participant/Payee:
John Crisler
13974 1h Street
South Haven, MI 49090
Amount: $200.00
Fund: Medical Escrow Fund (301)
Date: February 5, 2013
January 2013 Payment: $1,030.00
Adjusted Amount Due: -$830.00
Refund Check: $200.00
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
John Crisler Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
62105W3 62-05-13 lRetireee Health h9suFanee Premium Refund $200.00
Total $200.00
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.
02/1 TTTa--
ALLOWED 20
J�hn�.ri!�r IN SUM OF $
129 74th Street
South Ha can N 4anan
t200 nn
ON ACCOUNT OF APPROPRIATION FOR
go3 �4 -5
391 Merliral Rind
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
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund