223404 08/27/2013 Q4 CITY OF CARMEL, INDIANA VENDOR: 367504 Page 1 of 1
ONE CIVIC SQUARE DAVID BOLLES
IS 13855 SMOKEY RIDGE DRIVE CHECK AMOUNT: $202.50
i.�.? CARMEL, INDIANA 46032
•w .eN CARMEL IN 46033 CHECK NUMBER: 223404
CHECK DATE: 8/27/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4358400 202 . 50 REFUNDS AWARDS & INDE
PASS REFUND RECEIPT
I Receipt# 1138093
Payment Date: 08/21/13
Household #: 21107
Far sAccreation
Monon Community Center C IVED David Bolles Hm Ph: (317)815-0007
Carmel IN 46032 AUG 2 2 2013 CarmelINo460 Ridge Dr. Cell Ph:(317)501-3095
bridget.bolles@medmutual.com
Phone: (317)848-7275 $Y:
Fed Tax ID #35-6000972
Pass Details
CANCELLATION - Refund Of 67.50
Pass Holder: Breanna Bolles Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: 10-Visit(ESE1 OV), #187992 67.50 0.00 67.50 0.00 0.00
Valid Dates: 08/15/2012 to 05/29/2013 (Pass Cancellation)
Cancellation Effective: 08/21/2013
Cancel Reason: no longer need ese
CANCELLATION - Refund Of 135.00
Pass Holder: Lucy Bolles Fees+Tax Discount Prev Paid Cur Paid Amount Due
Pass Type: 10-Visit(ESEI OV), #182882 0.00 0.00 0.00 0.00 0.00
Valid Dates: 08/15/2012 to 05/29/2013 (Pass Cancellation)
Cancellation Effective: 08/21/2013
Pass Visit Info: Number of Visits: 15
PREVIOUS NET HOUSEHOLD BALANCE 0.00
Processed on 08/21/13 @ 11:55:42 by BJJ FEES CHANGED ON CANCELLED ITEMS(+) 202.50-
NET AMOUNT FROM CANCELLED ITEMS 202.50-
TOTAL AMOUNT REFUNDED 202.50
NEW NET HOUSEHOLD BALANCE 0.00
r
Refund of=_> 202.50 Made By==>REFUND FINAN With Reference=_>
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 or' ignature Date Authorized Signature Date
Escape Day Passes are non-refundable.
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.
Bolles, David Terms
13855 Smokey Ridge Dr. Date Due
Carmel, IN 46033
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
8/21/13 1138093 Refund $ 202.50
Total $ 202.50
1 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.
Bolles, David Allowed 20
13855 Smokey Rjdge Dr.
Carmel, IN 46033
In Sum of$
$ 202.50
ON ACCOUNT OF APPROPRIATION FOR
108 - ESE
PO#or Board Members
Dept#
INVOICE NO. ACCT#/TITL AMOUNT
1081-2 1138093 4358400 $ 202.50 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
Signature
$ 202.50 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund