223217 08/13/2013 CITY OF CARMEL, INDIANA VENDOR: 367449 Page 1 of 1
ONE CIVIC SQUARE GEORGE STOREY CHECK AMOUNT: $150.00
CARMEL, INDIANA 46032 10531 WILLIAMSON PARKWAY
''ISdrib'"� CARMEL IN 46032 CHECK NUMBER: 223217
CHECK DATE: 8/13/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 150 . 00 OTHER EXPENSES
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ITY °., { ARMEL
JA-,VIES BRAINARD, MAYOR
August 9, 2013
George Storey
10531 Williamson Parkway
Carmel, IN 46033
RE: Ticket 9 20130903:1 D.O.S. 03/07/2013 George Storey
Dear George Storey:
Enclosed you will find a reimbursement check in the amount of$ 150.00.
On May 23, 2013 we received your payment for $ 150.00.
Advantage Health reprocessed your claim and paid $ 150.00
on May 31, 2013 waiving your copayment.
The overpayment is your refund for $ 150.00.
If you have any questions, please feel free to contact me at (3)17) 571-2604.
Sincerely,
k"Ile
Michelle T. Harrington
Billing Administrator
CARNIEL FIRE DEPARTMENT
STEVEN A. COUTS HEADQUARTERS
Two Civic SQUARE, CARtiIEL. IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
S in.r'T'f YY,B.' c+L n;
A/R Detail
Type Transaction Adjudication Entered Amount Reference Memo Status
Date Date Date Number
Invoice 03/07/13 03/07/13 03/12/13 $420.30 Posted
Payment 05/10/13 05/10/13 05/10/13 ($183.80) CK 340280 Posted
WriteOff 05/10/13 05/10/13 05/10/13 ($86.50) CK 340280 Posted
Payment 05/23/13 05/23/13 05/23113 ($150.00) CK 5863 Posted
Payment 05/31/13 05131113 05131113 ($192.54) CK 343814 Posted
WriteOff 05/31/13 05/31/13 05/31/13 $42.54 CK 343814 Posted
Credit 08/09/13 08/09/13 08/09/13 $150.00 REFUND PT CK#586: 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.
ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
n �
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
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund