219753 05/07/2013 emu,, CITY OF CARMEL, INDIANA VENDOR: 120950 Page 1 of 1
ONE CIVIC SQUARE DOUGLAS HANEY CHECK AMOUNT: $15.46
CARMEL, INDIANA 46032 C/O DEPT OF LAW
C/O DEPT OF LAW CHECK NUMBER: 219753
CHECK DATE: 5/7/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1180 4230200 15 . 46 OFFICE SUPPLIES
STATE OF INDIANA )
) SS:
COUNTY OF HAMILTON )
AFFIDAVIT
I, Douglas C. Haney, Carmel City Attorney, being first duly sworn upon my oath, state that I
expended a total of Fifteen Dollars and Forty-Six Cents ($15.46) of my own monies to purchase the
I
following miscellaneous office supplies for the Department of Law:
Utilitech Flat Plug Cord purchased at Lowes on or about 3/30/13 for $7.47
Henley Essentials Portable Mini Keyboard Vacuum purchased from The Container Store on or
about 4/9/13 for $7.99
and for which I need to be reimbursed.
Dated this day of April, 2013.
Douglas ey
Y�K
,+1(7 y Sub'scnbed and sworn to before me, the undersigned Notary Public, this day of April,
2013:' . . .. a
94
t A4
%, A. Elaine Bass, NOTARY PUBLIC
tI1SlYi . V
Resident of Marion County, Indiana
My Commission Expires:
October 23, 2016
(eb:m ord:z\shuedtafdavitslaRadivit honey office supplies.doc'4/23/13]
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
Douglas C. Haney
Purchase Order No.
13828 Smokey Ridge Drive
Terms
Carmel, Indiana 46033 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4-22-13 Reimburse Douglas C. Haney for monies he personally
expended for Departmental office supplies per the
attached Affidavit:
Utilitech Fiat Plug Cord purchased at Lowes on 3130113 $7.47
Henley Keyboard VaGUUM purGhased 4,19-112-from Gontainpr Rtnre
TOTAII Total
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. �?
ALLOWED 20
Douglas C. Haney — IN SUM OF $
13828 Smokey Ridge Drive
Carmel, Indiana 46033
$ $15.46
ON ACCOUNT OF APPROPRIATION FOR
Department of Law
420-30200 Office Supplies
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
1180 $15.46 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
201_5
4UANO�
Cost distribution ledger classification if
claim paid motor vehicle highway fund