221676 07/02/2013 CIT'y orvil RMEL, INDIANA VENDOR: 367238 Page 1 of 1
ONE CIVIC SQUARE JESSICA RABUCK
CARMEL, INDIANA 46032 5315 E 75TH ST CHECK AMOUNT: $401.37
INDIANAPOLIS IN 46250 CHECK NUMBER: 221676
CHECK DATE: 7/2/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 401 . 37 OTHER EXPENSES
CITY« O ' EL
JAMES BRAINARD, MAYOR
June 28, 2013
Jessica Rabuck
5315E 751' Street
Indianapolis, IN 46250
RE: Ticket# 20130697:1 D.O.S. 02/20/2013
Dear Jessica Rabuck:
Enclosed you will find a reimbursement check in the amount of$401.37.
On March 8, 20li we received your payment for $ 445.37 and
IU Health Plan paid $ 401.37 on April 22, 20013.
Coinsurance amount $44.00 and the credit balance of$401.37 is your refund.
If you have any questions, please feel free to contact me at (3)17) 571-2604.
Sincerely,
kwzay �
Michelle T. Harrington
Billing Administrator
CAR,NIEL FIRE DEPARTMENT
STEVEN A. COUTS HEADQUARTERS
TWO CMG SQUARE, CARNIEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
1 �
S t7xG'T A R
A/R Detail
Type Transaction Adjudication Entered Amount Reference Memo Status
Date Date Date Number
Invoice 02/20/13 02/20/13 02/28/13 $445.97 ,Q (• �j Posted
Payment 03/08/13 03/08/13 03/08/13 ($445.97) CK 244496635 �e SS/�f "al7UG1� Posted
Payment 04/22/13 04/22/13 04/22/13 ($401.37) CK 004394 1u {-� Posted
Credit 06128/13 06128/13 06/28/13 $401.37 REFUND PATIENT JESSICA RABUCK Posted
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))
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
7� Ss� IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
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
JUL- --12013
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund