221607 07/02/2013 i
CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER CHECK AMOUNT: $51.35
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE
CARMEL IN 46032 CHECK NUMBER: 221607
CHECK DATE: 7/2/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 51 . 35 TRAVEL PER DIEMS
Prescribed by State Board of Accounts General Form No. 101(1955)
MILEAGE CLAIM
l}IYl TO r% LT;(� ��n 'A+e.t�X T DR.
Governments nit) �-y�
On Account of Appropriation No. q.36 _a for 11 r 1, licl ay
--(Office,Board,Department or institution)
DATE FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE @
20-Z-,3 Point Point Start Finish TRAVELED PER MILE
,
9 << 3
5 '73 S'
-�13 5 w �L
-/3 r ,r 3 k.� �� •�
t 9-5
3 � 11Je 3 45'
-/3 t. �� 1. rl rr
'k 5 9 Jf 9 3 990 '7
ew
Auto License No. TOTALS / /
* SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155,Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount .claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
Date J'I' /� A 4
Claim No. Warrant No. I have examined the within claim ca-id
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
' — That it is duly.authenticated as requi:
by law;
That it is based upon statutory,autho:
That it is appcarently, Correct
incorrect
On Account of Appropriation No.. for
Disbursing,OfBcer
(Q '0
Allowed F�!(
in the sum of$ �. �.� jOJ R
(CD
= N ((RD
(Docad or Commission)
FILED
A
(01 icial Me)
to
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