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HomeMy WebLinkAbout217340 02/13/2013 CITY OF CARMEL, INDIANA VENDOR: 00350917 Page 1 of 1 : ONE CIVIC SQUARE KIM ROTT CHECK AMOUNT: $652.30 CARMEL, INDIANA 46032 1303 HOLLYCREST DRIVE BLOOMINGTON IL 61701 CHECK NUMBER: 217340 CHECK DATE: 2/13/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 301 5023990 652 . 30 OTHER EXPENSES Retiree Health Insurance Premium Refund Authorized by Ordinance D-2123-13 Plan Participant/Payee: Kimberly Rott 1303 Hollycrest Drive Bloomington, IL 61701 Amount: $352.30 Fund: Medical Escrow Fund (301) Date: February 5, 2013 January/February 2013 Payment: $1,570.00 Adjusted Amount Due: 41,217.70 Refund Check: $352.30 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 Kimberly Rott Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 0 Total $352.30 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. 11 02 ALLOWED 20 Kimberly Rnt - IN SUM OF $ 1203 HollyGrost nrlV®11 A17AI kqnm'ngtnrj, $_ $352.30 ON ACCOUNT OF APPROPRIATION FOR al �i d in a,--r-crr,- Board Members PO#or D PT.# INVOICE NO. ACCT#/TITLE AMOUNT I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the BEH materials or services itemized thereon for which charge is made were ordered and received except 20 Signature Title Cost distribution ledger classification if f claim paid motor vehicle highway fund i City of Carmel Employee Health Benefit Plan Health Savings Account Incentive The retired plan participant listed below has elected Plan A for 2013 and is eligible for a bi- annual contribution to his or her HSA account, as authorized by Resolution BPW-10-03-12-02. Please return check to Human Resources for further processing Plan Participant/Payee: Kimberly Rott 1303 Hollycrest Drive Bloomington, IL 61701 Amount: $300.00 Fund: Medical Escrow Fund (301) Date: February 5, 2013 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 Kimberly Rott Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 62185/13 02.65.13 Health Savings Aeeeunt Ineentive $300.00 Total $300.00 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.0I11 WARRANT NO. TTT� ALLOWED 20 Kimberly Rntt — IN SUM OF $ '13n rPCt nrIVP Bloomington 11 61701 $ $300.00 ON ACCOUNT OF APPROPRIATION FOR 301 MArliral Fl Ind 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