HomeMy WebLinkAbout223093 08/13/2013 CITY OF CARMEL, INDIANA VENDOR: 367448 Page 1 of 1
ONE CIVIC SQUARE SIGRUN MOORE CHECK AMOUNT: $75.00
CARMEL, INDIANA 46032 9104 WOODBRIDGE CT
INDIANAPOLIS IN 46260 CHECK NUMBER: 223093
CHECK DATE: 8/13/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 75 . 00 OTHER EXPENSES
i
CITY O]F EL
JA_1IEs BRAINARD, MAYOR
August 9, 201
Sigrun Moore
9104 Woodbridge Ct
Indianapolis, IN 46260
RE: Ticket 9 20130967:1 D.O.S. 03/11/2013 Sigrun Moore
Dear Sigrun Moore:
Enclosed you will find a reimbursement check in the amount of$ 75.00.
On May 17, 2013 we received your payment for $ 75.00.
Advantage Health reprocessed your claim and paid $ 75.00
on May 31, 2013 waiving your copayment.
The overpayment is your refund for $ 75.00.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
Billing Administrator
CARMEL FIRE DEPARTME\T
STEVEN A. COUTs HEADQUARTERS
Tw;r� Civic C IRARF C,PmFi TN 4OOA2 C)FFTC.F �M.571.2600. FAX 317.571.2615
sOTT�PAAaE 1
A/R Detail
Type Transaction Adjudication Entered Amount Reference Memo Status
Date Date Date Number
Invoice 03/11/13 03111/13 03/15/13 $450.50 ReadyToPost
Payment 05/10/13 05/10/13 05/10/13 ($258.80) CK 340280 Posted
WriteOff 05/10/13 05/10/13 05/10/13 ($116.70) CK 340280 Posted
Payment 05/17/13 05/17/13 05/17/13 ($75.00) CK 6531 // Posted
Payment 05/31113 05/31/13 05/31/13 ($75.00) CK 343814 �G{vQp,�Cp9e Posted
Credit 08/09/13 08/09/13 08/09/13 $75.00 CK#6531 REFUND C ADVANTAGE REPROPosted
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.
C ALLOWED 20
IN SUM OF $
. .o Q
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
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund