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
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$_ $352.30
ON ACCOUNT OF APPROPRIATION FOR
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in
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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