218133 03/13/2013 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
CARMEL IN 46032 CHECK NUMBER: 218133
CHECK DATE: 3113/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 15 . 80 TRAVEL PER DIEMS
Prescrlbed by State Board of Accounts General Form No.101(1955)
MILEAGE CLAIM
-Wern TO ���� �i11� �n A+�fli�,E' i�-� DR.
(Governmental nit) c
D ��r 2� • / �� On Account of Appropriation No. O -J! for .
(Offce,Board,Department or Institution
DATE_- ` FROM TO ODOMETER READING' NATURE OF BUSINESS AUTO MILES MILEAGE @
20�� Point Point Start Finish TRAVELED PER MILE
JA
a5 ��- c� .� �1 �, a o� „� c� 9
Auto License No. TOTALS A5 TJ
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, 1 hereby certify that the foregoing account 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 JJ�5--lj
Claim No. Warrant No: I have examined the within claim and
hereby certify as follows:
` IN FAVOR OF _
That it is in proper form;
That it is duly authenticated as requi
by law;
That it is based upon,statutory author
correct.
That it is apparently
�. A6 - -' - incorrect
_ on Account of Appropriation No.y -C) for
- -
,. Disbursing Officer
: Allowed - - ,20 - -
- - sum the of
in $
- _ 0j,
0
!' C)
_ _. . . (Board or Commission)
FILED
.i rn.
(Official Title)
(D
y
O
y