217239 02/13/2013 - CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $15.80
o+ CARMEL IN 46032
CHECK NUMBER: 217239
CHECK DATE: 211312013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 15 . 80 TRAVEL PER DIEMS
Prescribed by State Board of Accounts MILEAGE CLAIM General Form No,101 (1955)
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Zp'_r' j � � TO f C►-�F ( '_:i1iC' p �A�e. sj T DR.
(GovernoreentaT Onit
1 [ U-b On Account of Appropriation No. � d -6 for '
Office,Board, epart ment or Ins t(tution
Sao.
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE @ a4
Zp Point Point Start Finish TRAVELED PER MILE
t \,— (t / - 17
L. <l S- ci
_s
�. q / �?
3 s
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I
Auto License No.
TOTALS
SPEE=DOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Purs uant to the provisions and penalties of Chapter 155 Acts 1953 1 hereby certi fy that the for ego i ng a cc ount is just and correct, that the amount claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
Date ��o ' �� ✓I ��
i
Claim No. Warrorit No.,_______ I have ex=ined the withia-1 claim M-X,
hereby certify as follows:
IN FAVOR OP '
That it is in proper farm;
That it is duly authenticated,as rte .
by law;
That it is based upon statutory aj4tho.
That it is apparently Correct
incorrect
On Account of Appropriation No.U--y for
i
Disbursing Offlcer
Allowed 20 M
in the sum of
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