226143 11/18/2013 *F CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $84.91
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 226143
CHECK DATE: 11118/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 21476 84 . 91 MEDICAL FEES
INVOICE
Public Safety Medical Services OCT 1
r 324 E. New York Street 8 2013
E: Suite 300
I= Indianapolis, IN 46204 LB-YY
G- Carmel Clay Parks& Recreation/CARMELPARK
-E— Attn: Jeff Kramer Terms
1411 E. 116th Street Invoice Date 10/1612013
act Invoice# 00-21476
Carmel, IN 46032
Date Employee Description Amount Balance Due
10/07/13 Koch Carol C. Hepatitis B Vacc#3 $74.29 74.29
In ection Fee $10.62 $10.62
F� Total Charges > $84.91
Total Payments&Balance Due->: $0.00 $84.91
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35-2079797 _
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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.
00350364 Public Safety Medical Services Terms
324 E. New York Street, Ste 300
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s)) PO# Amount
10/16/13 21476 Medical fees $ 84.91
Total $ 84.91
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.
00350364 Public Safety Medical Services Allowed 20
324 E. New York Street, Ste 300
Indianapolis, IN 46204
In Sum of$
$ 84.91
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO#or INVOICE NO. ACCT#/TITL AMOUNT Board Members
Dept#
1081-99 21476 4340700 $ 84.91 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
14-Nov 2013
Signature
$ 84.91 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund