223060 08/13/2013 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER
' ��• CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $75.05
CARMEL IN 46032 CHECK NUMBER: 223060
CHECK DATE: 8/13/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 75 . 05 TRAVEL PER DIEMS
prescribed by State Board of Accounts MILEAGE�±C /+pp pp p� General Form No, 101 (1955)
MILEAGE CILAIM
r
TO SP DR.
' Governments nit) —
_ On Account of Appropriation No. q36 -6 form, e-V�r
` —(Uff—Ice,Board,Department or InstitUtionj
DATE :'FROM TO /
ODOMETER READING* NATURE OF BUSINESS j AUTO MILES MILEAGE @
20 Point Point Start Finish TRAVELED PER MILE
,7 7a 5
p
Li rl s �� t C
s 44IE2 1.1 tl - 3 S
" t t (1 " In t
Lt
-7�J�_ V\
-7 Pil 37 L/7 3 ell 1
J
L/ k ;r
r t qyq S"o LA t
-7-31 2 t L 1 " A �t /71
Auto:License No. TOTALS
"SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
:Pursuant to the provisions and penalties of Chapter 155,Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount claim ally due, afte
allowing all just credits, and that no part of the same has been paid.
Date
Claim No. Warrant No, I have examined the within claiin ca-id
hereby certify as follows:
IN FAVOR OF
} That it is in proper form;
Prim ` That it is-duly authenticated as regal
_ by law;
That it is based upon`statutory author
That it i-s apparently { incorrect
On Accountof A PP P ro riatiori No. -cAl for
-Disbursing Officer -
Q 10
O
Allowed 20 - N n
in the sum of$ ���, O S� .. _-- -._. . o EF
u.
i _ N
rt
N - 0
(Board or Commission)
FILED .
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. . (O(li6101 Title)
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