217318 02/13/2013 CITY OF CARMEL, INDIANA VENDOR: 00350846 Page 1 of 1
!' ONE CIVIC SQUARE KIMBERLY K.PRATT
i
CARMEL, INDIANA 46032 1063 ARROWWOOD DRIVE CHECK AMOUNT: $440.96
CARMEL IN 46033 CHECK NUMBER: 217318
CHECK DATE: 2/13/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 20513 440 . 96 OTHER EXPENSES
Retiree Health Insurance Premium Refund
Authorized by Ordinance D-2123-13
Plan Participant/Payee:
Kimberly Pratt
1063 Arrowwood Drive
Carmel, IN 46033
Amount: $440.96
Fund: Medical Escrow Fund (301)
Date: February 5, 2013
January 2013 Payment: $1,188.73
Adjusted Amount Due: 4747.77
Refund Check: $440.96
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.207(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
Kimberly Pratt Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0
Total $440.96
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 N00211T/12 WARRANT NO.
ALLOWED 20
Kimberly Pratt IN SUM OF $
1063 Arrowwood Drive
Carmel, IN 46033
$ $440.96
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
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
02.05.13 301 $440.96 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