225885 11/05/2013 CITY OF CARMEL, INDIANA VENDOR: 362732 Page 1 of 1
ONE CIVIC SQUARE PAMELA LISTER CHECK AMOUNT: $55.30
CARMEL, INDIANA 46032 11598 MANSFIELD PLACE
CARMEL IN 46032 CHECK NUMBER: 225885
CHECK DATE: 11/5/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4343004 55 . 30 TRAVEL PER DIEMS
Prescribed by Slate Board of Accounts General Form No 101(1955)
MILEAGE CLAIM /�
?' 'orn TO�(G;i 1 c� n. (''F1+2 to�X ice-' _D R.
(Governmental nit)
On Account of Appropriation No. �� a -!S for , cr 4i11
kurrice,Board,Department or`Inst tut on
DATE - FROM TO ODOMETER READING* NATURE OF BUSINESS AUTO MILES MILEAGE
i
20 Point- Point Start Finish TRAVELED PER MILE
3
!1 \X_ 75
D _ (, t '7- 3
.17 95
3 s
0
\ c
ll
lti Q l• !(
Auto License No. TOTALS H Y
" SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map. .
Pursuant to the provisions and penalties of Chapter 155,Acts 1953, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally du , fter
allowing all just credits, and that no part of the same has been paid.
Date
T
Claim No. Warrant No. _ I have examuzed the within claiun and
hereby certify as follows:
IN FAVOR OF
That it is in proper form;
►/ ' �"" That it is duly authenticated•as requi:
by law;
That it is based upon statutory autho:
That it is apparently Correct
incorrect
On Account of Appropriation-No. for
Disbursing Officer
- cQ'0
Allowed - 20 -
in the sum of$ o
N O
(Board oI Commission) •y
FILED in
n
(Official Title)
to
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