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HomeMy WebLinkAbout222937 08/13/2013 CITY OF CARMEL, INDIANA VENDOR: 367456 Page 1 of 1 ONE CIVIC SQUARE EARL FYFFE CARMEL, INDIANA 46032 CHECK AMOUNT: $394.63 3724 HOLLY ST GROVE CITY OH 43123 CHECK NUMBER: 222937 CHECK DATE: 8/13/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 394 . 63 OTHER EXPENSES �r m CITY O EL J,NmES BRAINARD, NLAYOR August 9, 2013 Earl Fyffe 3724 Holly Street Grove City, OH 43123 RE: Ticket# 20125220:1 D.O.S. 11/15/2012 Earl Fyffe Dear Earl Fyffe: Enclosed you will find a reimbursement check in the amount of$ 394.63. On January 15, 2013 we received your payment for $ 394.63. CareWorks paid $ 394.63 on July 29, 2013 for your worker's compensation claim. The overpayment is your refund for $ 394.63. If you have any questions, please feel free to contact me at (3)17) 571-2604. Sincerely, Michelle T. Harrington Billing Administrator CARAIEL FIRE DEPARTNIENT STEVEN A. COUTs HEADQUARTERS Two CIVIC SQUARE, CAR IEL, IN 46032 OEEIcE 317.571.2600, FAx 317.571.2615 0 n'T•dl 6,it f r A/R Detail Type Transaction Adjudication Entered Amount Reference Memo Status Date Date Date Number Invoice 11/15/12 11/15/12 11/14/12 $394.63 Posted Payment 01/15/13 01/15/13 01/14/13 ($394.63) CC EARL FYFFE CC 970(Posted Payment 07130/13 07/30/13 07/30/13 ($394.63) 5776533 Posted Credit 08/09/13 08/09/13 08/09/13 $394.63 REFUND PATIENT WORKERS CCOMP CPosted 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 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 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 boa 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