220633 06/04/2013 CITY OF CARMEL, INDIANA VENDOR: 367198 Page 1 of 1
ONE CIVIC SQUARE SIEGMUND HAIDER
i CHECK AMOUNT: $44.23
�o CARMEL, INDIANA 46032 600 W 106TH STREET
CARMEL IN 46032 CHECK NUMBER: 220633
CHECK DATE: 614/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1092 4358400 44 . 23 REFUNDS AWARDS & INDE
GLOBAL REFUND RECEIPT
Receipt# 1056080
Carrel a Clay Payment Date: 05/30/13
Household #: 16694
Parks&Recreation
Monon Community Center Siegmund Haider Hm Ph: (317)846-6798
Carmel IN 46032 600 W. 106th Street
I
JUN 0 3 2013 Carmel IN 46032 Cell Ph:
mabepi @aol.com
Phone: (317)848-7275 �
Fed Tax ID#35-6000972 —_-----
Pass Details
CANCELLATION - Refund Of 44.23
Pass Holder: Siegmund Haider Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: MC Adlt Annual (M MCAA), #91189 375.77 0.00 375.77 0.00 0.00
Valid Dates: 06124/2012 to 07109/2013 (Pass Cancellation)
Cancellation Effective: 05/30/2013
Cancel Reason: very ill in Austria . Giving back 39 days plus wants left on his yearly pass. HPG
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 05/30/13 @ 15:34:10 by HPG FEES CHANGED ON CANCELLED ITEMS(+) 44.23-
NET AMOUNT FROM CANCELLED ITEMS 44.23-
TOTAL AMOUNT REFUNDED 44.23
NEW NET HOUSEHOLD BALANCE 0.00
Refund of=_> 44.23 Made By==>REFUND FINAN With Reference=_>
All refunds are subject to State Board of Accounts procedures and may take 4-6 week§4 process. No cash refunds will be
issued.
Authorized Signature Date Authorized Si atur D to
Escape Day Passes are non-refundable.
Page# 1 of 1
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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 Purchase Order No.
Haider, Siegmund Terms
600 W 106th Street Date Due
Carmel, IN 46032
;5/3;0/1 Z1056080 TRe;fund Description
;(or ote;attached invoice(s) or bill(s)) Amount
$ 44.23
Total $ 44.23
I hereby certify that the attached invoice(s), or bill(s)is(are)true and correct and 1 have audited same in accordance
with IC 5-11-10-1.6
20_
Clerk-Treasurer
Voucher No. Warrant No.
Haider, Siegmund Allowed 20
600 W 106th Street
Carmel, IN 46032
In Sum of$
$ 44.23
ON ACCOUNT OF APPROPRIATION FOR
109 - Monon Center
PO#or Board Members
Dept# INVOICE NO. ACCT#/TITLE AMOUNT
1092 1056080 4358400 $ 44.23 1 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
3-Jun 2013
Ah' '/W&M&4
Si nature
$ 44.23 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund