225960 11/05/2013 CITY OF CARMEL, INDIANA VENDOR: 366169 Page 1 of 1
ONE CIVIC SQUARE RYAN HOMES
CARMEL INDIANA 46032 3865 PRIORITY WAY S DRIVE#110 CHECK AMOUNT: $1,679.00
,
INDIANAPOLIS IN 46240 CHECK NUMBER: 225960
CHECK DATE: 11/5/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 REFUND 1, 679 . 00 REFUND
i
*COV(PLETE Est RETURN
REFUND REQUEST THIS FORM TO:
Cic of Carmel
f
Building.&
Code Services Y
b . Building Ea Code Services
Ph. (317) X71-:2444 Fax(317) 571-2499 1
One Civic Square;
Carmel, LN 46032
PERMIT #(s): ( � Og dO
Lot & Subdivision, or Address of Construction
s t 2-
(If more than one address needs to be listed and.will not fit, please'attach a printed list of all permits,with
their corresponding permit#.)
Please print or type the reason for the requested refund, and specific fee or fees.
which are requested, in the lines below:
.e.-
` 0 C�
TOTAL REFUND AINIpL`N'T REQLiESTED:
# 11,J
Applicant Signature Date
i
Applicant Name=Printed �� Company Name(If applicable)
1
APPLICANT ADDRESS,
c
Street Address
city ST zip:
x317 F-f
Phone# Fax..#
i
r
FOR OFFICE USE ONLY:
p Total amount for fees that ARE available.for refund:
F Fees that are NOT available for refund:
p Refund approved by: 1 ' Y\ Date: 1OI2�113
p Date.subrimitted for Payment: Amount Approved:
I
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
/PcJftA� #61nes Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
6 ca-
Total 1'"7(9•0v
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
�yAN 1�D/�7GS IN SUM OF $
S'u�f-e. iio
���rJ�°aLi�, i r✓ cI�,�, �U
ON ACCOUNT OF APPROPRIATION FOR
6ZN- mot)
Board Members
PO#or INVOICE NO. ACCT#!TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
p/ •-d 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
20
a
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund