223451 08/27/2013 CITY OF CARMEL, INDIANA VENDOR: 356897 Page 1 of 1
0 ONE CIVIC SQUARE SARA DORSTEN
CARMEL, INDIANA 46032 13211 CARMICHAEL LANE CHECK AMOUNT: $55.00
WESTFIELD IN 46074 CHECK NUMBER: 223451
CHECK DATE: 8/27/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4358400 55 . 00 REFUNDS AWARDS & INDE
GLOBAL REFUND RECEIPT
Receipt# 1137573
a eI o ]a Payment Date: 08/19/13
9 Household #: 20510
Par sAccrea ion
Monon Community Center Sara Dorsten Hm Ph: (317)571-8842
Carmel IN 46032 AUG 2 0 2013 13211 Carmichael Lane Wk Ph: (317)582-0642
Westfield IN 46074 Cell Ph:(317)797-9842
sara.fischer@ optum.com
Phone: (317)848-7275
Fed Tax ID#35-6000972
Refund Details
Orio Bal Refund New Bal
Module: Pass Management 55.00- 55.00 0.00
PREVIOUS NET CREDIT HOUSEHOLD BALANCE 55.00
Processed on 08/19/13 @ 10:19:03 by BJJ NEW REFUND AMOUNT() 55.00
TOTAL REFUNDABLE AMOUNT 55.00
NEW NET HOUSEHOLD BALANCE 0.00
Refund of=_> 55.00 Made By==>REFUND FINAN With Reference==>1081-2-4358400
All refunds are subject to State Board of Accounts procedures and may take 4-6 weeks to process. No cash refunds will be
issued.
Au on ignature Date Authorized Signature Date
Escape Day Passes are non-refundable.
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P^ '
Page# 1 of 1
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
Dorsten, Sara Terms
13211 Carmichael Lane Date Due
Westfield, IN 46074
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
8/19/13 1137573 Refund $ 55.00
I
Total $ 55.00
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.
Dorsten, Sara Allowed 20
13211 Carmichael Lane
Westfield, IN 46074
In Sum of$ '
$ 55.00
ON ACCOUNT OF APPROPRIATION FOR
108 - ESE
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
Dept#
1081-2 1137573 4358400 $ 55.00 1 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
22-Aug 2013
&Mm mo
Signature
$ 55.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund