221772 07/02/2013 CITY OF CARMEL, INDIANA VENDOR: 360212 Page 1 of 1
ONE CIVIC SQUARE MATT WORTHLEY
CARMEL, INDIANA 46032 cio CRC CHECK AMOUNT: $286.92
CHECK NUMBER: 221772
CHECK DATE: 7/2/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1801 4350900 54 . 00 2346
1801 4350900 7 . 92 2465588
1801 4350900 225 . 00 62413
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;Billing/Shipping Information
customer name: Worthley Matthew Dane billing name: Worthley Matthew Dane
email: matt.worthley @gmail.com contact: Worthley Matthew Dane
phone: (317)205-7030
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shipping label: Mr.Matthew Dane Worthley billing label: Mr. Matthew Dane Worthley
57 11th Street NW 57 11th Street NW
I Carmel, IN 46032 Carmel, IN 46032
UNITED STATES UNITED STATES
Payment Information
payment amount: 225.00 net-total: 225.00
payment method: Credit Card USD net-applied: 225.00
net-balance: 0.00
authorization code: 050458
reference number: VLFA9BCB9519
i currency: USD - United States Dollar
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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
6wekl 0/'/'� % Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice (s) or bill(s))
�-2�—f3 62y13 r imd r rn Vr Ldp► .� 2 2.5
� e bPr hi
2��3 236 ``►► r e S ao
'44 reirnkrs 12
Total
I 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
60ey QrA le c/ IN SUM OF $
2 �6,92.
ON ACCOUNT OF APPROPRIATION FOR
Sol/ 4356%
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
2-413 9350916 22,5°b. 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
7- 013
79-ignature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund