217223 02/13/2013 CITY OF CARMEL, INDIANA VENDOR: 00350185 Page 1 of 1
0 ONE CIVIC SQUARE BILL KEHL
CARMEL, INDIANA 46032 8645 SOUTH STREET CHECK AMOUNT: $200.00
FISHERS IN 46038
CHECK NUMBER: 217223
CHECK DATE: 2/13/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 200 . 00 REFUND
Retiree Health Insurance Premium Refund
Authorized by Ordinance D-2123-13
Plan Participant/Payee:
William Kehl
8645 South Street
Fishers, IN 46038
Amount: $200.00
Fund: Medical Escrow Fund (301)
Date: February 5, 2013
January 2013 Payment: $1,030.00
Adjusted Amount Due: 4830.00
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
William Kehl Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
02K)SM3 02-8513 Retur e Health insuranee 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.
ALLOWED 20
William KPhI - IN SUM OF $
8645 South Street
Fishers IN 46038
ON ACCOUNT OF APPROPRIATION FOR
'1711 Medical E!Ind
Board Members
PO#or DEPT# INVOICE NO. ACCT#/TITLE AMOUNT I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
090513 S200M 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