224974 10/08/2013 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE CHECK AMOUNT: $79.00
CARMEL IN 46032 CHECK NUMBER: 224974
ON�
CHECK DATE: 10/8/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 79 . 00 TRAVEL PER DIEMS
Prescribed by Stale Board of Accounts General Form No.101(1955)
MILEAGE CLAIM
DR.
Governments nit) `�
On Account of Appropriation No. 4..36 _a for , it
Office Board,Uepartment or Institution
DATE FROM TO ODOMETER READING" NATURE OF BUSINESS AUTO MILES MILEAGE @
20 Point Point Start Finish TRAVELED PER MILE
K _ / p
777, 1v 7
D9J \( ,
Lt '17
Ll. �f '>
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, ! a3 ao Lr .3
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7
Auto License No. TOTALS OZJ
" 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, 1 hereby certify that the foregoing account is just and correct, that the amount claimed i due, after
allowing all just credits, and that no part of the same has been paid.
Date '3��/3 l?
Claim No. Warrant No. I have exc mil led the within claun and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
Pam
. -That it is duly uthenticated as r
Y eciw•
—- - ..-- -
'by law;
That.it is based upon statutory author
_ (�
That it is apparently {in o eat
On Account of Appropriation No. -O for -
Disbursing Olflmr
Q 10
NAllowed 20 _
in the sum of$ ' ) _..
m
ro
Cl
(B=d or Commission)
M
FILED
In'
ro
(Official Title)
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