221504 07/02/2013 CITY OF CARMEL, INDIANA VENDOR: 367254 Page 1 of 1
ONE CIVIC SQUARE JESSICA FREUND CHECK AMOUNT: $384.83
% CARMEL, INDIANA 46032 5990 TYBALT CIRCLE
INDIANAPOLIS IN 46254 CHECK NUMBER: 221504
ETON�
CHECK DATE: 7/2/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 384 . 83 REFUND
C1 EL
JAMES BRAINARD, NLAYOR
June 28, 2013
Jessica Freund
5990 Tybalt Circle
Indianapolis, IN 46254
RE: Ticket# 20123425:1 D.O.S. 08/01/2012 Jack Freund
Dear Jessica Freund:
Enclosed you will find a reimbursement check in the amount of$ 384.83.
On September 25, 2012 we received your payment for $ 481.04 and
Pro Health paid $ 384.83 on October 15, 2012. Your Copayment was $ 96.21.
The overpayment is your refund for $ 384.83.
If you have any questions, please feel free to contact me at (3)17) 571-2604.
Sincerely,
Michelle T. Harrington
Billing Administrator
CARMEL FIRE DEPART\PENT
STEVE\ A. CouTs HEADQUARTERS
Two CIVIC SQUARE, CARINIFL, IN 46032 OFFICE 317.571.2600, FA-x 317.571.2615
s ,. '- .6 f ,T101ARt 9_+,
A/R Detail
Type Transaction Adjudication Entered Amount Reference Memo Status
Date Date Date Number
Invoice 08/01/12 08/01/12 07/31/12 $481.04 Posted
Payment 09/26/12 09/26/12 09/25/12 ($481.04) CK J�(p,C JowCA FREUND CKPosted
Payment 10/16/12 10116/12 10/15/12 ($384.83) CK C)J08bgg2, PROHEALTH CK 020£Posted
Credit 06/28/13 06/28/13 06/28/13 $384.83 REFUND JESSICA FR OVERPAYMENT Posted
I
I
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total -3"U�,•°�S
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
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
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
JUL
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund