221836 07/11/2013 CITY OF CARMEL, INDIANA VENDOR: 079900 Page 1 of 1
ONE CIVIC SQUARE GARY DUFEK
CARMEL, INDIANA 46032 12610 OVERTURE DRIVE CHECK AMOUNT: $300.00
CARMEL IN 46033
CHECK NUMBER: 221836
CHECK DATE: 7/11/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 300 . 00 OTHER EXPENSES
City of Carmel Employee Health Benefit Plan
Health Savings Account Incentive
The retired plan participant listed below has elected Plan A for 2013 and is eligible for a bi-
annual contribution to his or her HSA account, as authorized by Resolution BPW-10-03-12-02.
Please return check to Human Resources for further processing.
Plan Participant/Payee:
I
Gary Dufek
12610 Overture Drive
Carmel, IN 46033
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: July 11, 2013
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
Gary Dufek Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
07/11/13 HSA Contribution 3nn 00
I
Total $300.00
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 Nc97/11/13 WARRANT NO.
Gary Dufek ALLOWED 20
IN SUM OF $
12610 Overture Drive
Carmel, IN 46033
$ $300.00
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
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
$i MO.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund