221839 07/11/2013 CITY OF CARMEL, INDIANA VENDOR: 358069 Page 1 of 1
ONE CIVIC SQUARE KIMBERLY BABB
: CARMEL, INDIANA 46032 CHECK AMOUNT: $200.00
CHECK NUMBER: 221839
CHECK DATE: 7/11/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 200 . 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.
I_
Plan Participant/Payee:
Kimberly Babb
14138 Shelborne Road
Westfield, IN 46074
Amount: $200.00
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
Kimberly Babb 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
Total 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 NO)7/11/13 WARRANT NO.
Kimberly Babb ALLOWED 20
IN SUM OF $
14138 Shelbourne Road
Westfield, IN 46074
Zo 0
w
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
materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund