221620 07/02/2013 CITY OF CARMEL, INDIANA VENDOR: 204038 Page 1 of 1
r ONE CIVIC SQUARE MIDWEST TOXICOLOGY SVS,INC CHECK AMOUNT: $33.00
CARMEL, INDIANA 46032 603 E WASHINGTON ST SUITE 200
INDIANAPOLIS IN 46204 CHECK NUMBER: 221620
CHECK DATE: 7/2/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4340799 7509 33 . 00 OTHER MEDICAL FEES
Invoice 44* Payment Due Date Invoice#
Upon Receipt 3/31/2013 7509
603 E.Washington Street,Suite 200,Indianapolis,IN 46204
Bill To Ship To
City of Carmel Names & location of collection
Attn: Jim Spelbring on invoices - no ss#!!
1 Civic Square Email results to Barb Lamb & cc Jim .
Carmel, IN 46032 Still Mail results to Jim
P.O. Number Project/Jobsite Control# Rep
5528 NM
Qty. Item Code Description Price Each Class Amount
1 ND Alcohol CS Non-DOT Alcohol Test 28.00 Indiana 28.00
Collected at St.Vincent Carmel Hospital
7/26/12
Richard Viehe
1 CS Surcharge Alcohol Please note that you are being charged an additional fee due to your 5.00 Indiana 5.00
collection site breath alcohol charges.
Note: During an account audit we found these tests had not been invoiced.
If you have any questions, please call 317-269-3035.
I
By
A finance charge will be assessed on all invoices not paid in 30 days.Thank you for your business!
Total $33.00
Make checks payable to:Midwest Toxicology Services,LLC
I
For questions regarding this invoice,contact us at 317-269-3029 or fax us at 317-262-2222.Be sure to visit our website at www.midwesttoxicology.com
Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
ACCOUNTS PAYABLE VOUCHER
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))
7509 Accident Screen $33.00
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
Midwest Toxicology
IN SUM OF $
603 E. Washington Street, Ste. 200
Indianapolis, IN 46204
$33.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. I ACCT#!TITLE AMOUNT Board Members
1120 I 7509 I 43-407.99 I $33.00 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
JUL 1.2013
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund